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 risk for breast cancer. Findings: Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient was noted to have breasts that are heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically this subset of 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. In addition, the findings of nodules and cysts seen on the whole breast automated sonogram can be further evaluated by tomosynthesis, though, as in this patient, a targeted sonogram is also of value. Thus, in this clinical setting, the use of the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male enrollee has requested authorization and coverage for left total ankle replacement with Salto Talaris ankle prosthesis for treatment of his advanced post-traumatic arthritis. Findings:  Two physician reviewers found that the specific prosthesis requested by this patient has been approved by the Food and Drug Administration for treatment of patients with advanced ankle arthritis. The results of total ankle replacement are comparable to the results of ankle fusion with respect to the alleviation of pain and improvement in function. Furthermore, total ankle replacement avoids the most severe complication of ankle fusion which is the development of premature degenerative disease in other joints of the foot including, but not limited to, the subtalar joint and the first metatarsal phalangeal joint. Thus, total ankle replacement is likely to be a more efficacious option for this patient. The procedure offers a strong likelihood of pain relief comparable to that of ankle fusion, without the associated complications of developing premature arthritis in other joints of the foot that would be even more debilitating. This patient already demonstrates decreased motion in the subtalar joint which would likely be aggravated by ankle fusion.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested cervical nerve ablation for treatment of her neck pain. Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Radiofrequency ablation is supported in the peer-reviewed literature in this clinical setting. In this case, the patient has had failure of several modalities of treatments. The patient presents with chronic persistent pain with findings of significant facet arthritis.  Final Result:  Two 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: All three reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 44-year-old female enrollee has requested Aranesp for the treatment of her chemotherapy-related anemia and fatigue. Findings:  The physician reviewer found that as of 2007, the current guidelines from the American Society of Clinical Oncology and the American Society for Hematology support the use of erythropoietin factors to maintain or increase hemoglobin in patients receiving chemotherapy. The guidelines suggest an equivalence between Procrit and Aranesp, and do not require the use of one before the other. The guidelines also state that erythropoietin factors are indicated when hemoglobin is approaching, or has fallen below, 10g/dl, to increase hemoglobin and decrease transfusions.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of an eight-year-old female enrollee has requested The Vest Airway Clearance System for the treatment of the enrollees chronic pulmonary condition. Findings:  Three physician reviewers found that while it is true that there is little medical literature studying the use of The Vest in this, or in analogous clinical situations, there have been anecdotal reports of benefit in cases such as this. In fact, this patient has received a trial of The Vest with good results. Based on this individual patients positive response to the therapy, and with an intuitive extrapolation of published literature, it is our opinion that use of The Vest in this case is also likely to be more beneficial for this patient than any available standard treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 58-year-old male enrollee requested cortisone injections/selective nerve root block (SNRB) for medical treatment of his flat back syndrome due to spinal fusion from L1-S1.  Findings:  The physician reviewer found that the patients physical exam is not consistent with thoracic radicular pain or facet pain for which the combination of injections was required.   Additionally, there is lack of documentation of an MRI of the thoracic or lumbar spine to provide corroborating evidence for the treatment provided. The peer-reviewed medical literature provides evidence for epidural steroid injections and facet injections in documented cases of nerve root compression or facet arthropathy. However, given the lack of documentation in the medical records of pathological findings consistent with radicular pain and/or facet pain, the treatment requested was not indicated.
Appeal type: Medical Necessity
Decision: Overturned

A 58-year-old female enrollee has requested a panniculectomy for treatment of her status post gastric bypass.  Findings:  The physician reviewer found that in this patients case, a symptomatic abdominal pannus is well-documented. The photographs also support this finding.  Based upon the submitted medical records, this is a functional issue, as the redundant tissue has caused rashes and infections.  These functional concerns have been supported by multiple physicians in different areas of practice. The requested surgery is likely to improve this patients symptoms. In summary, the medical documentation supports a functional problem following weight loss surgery that can be relieved with a panniculectomy.  All told, the requested panniculectomy is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested  abdominoplasty (CPT codes 15830 and 15847) for treatment of her excess skin. Findings:  The physician reviewer found that the requested abdominoplasty is not medically necessary for treatment of the patients medical condition. Abdominoplasty (CPT 15847) is a cosmetic procedure that involves placement of transverse suprapubic/lower abdominal and periumbilical incisions. The abdominal skin is then tightened by excising the caudal portion of abdominal skin and creating a new umbilical opening higher up on the skin that has now been stretched downward. In most cases tightening of the abdominal musculature is also performed by suture plication of the rectus sheaths. This maneuver repairs a diastasis recti which is a widening of the linea alba with separation of the rectus muscles. Unlike a hernia, diastasis is a benign condition with no long term sequelae because the intestines and omentum cannot escape from the intra-abdominal space via the diastasis. It is not a medically necessary procedure unless the excess skin is required to close an open wound rather than being removed for cosmetic reasons. Therefore, the requested abdominoplasty (CPT 15847) is not medically necessary in this clinical setting.In addition, her surgeon recommends a staged belt lipectomy (CPT 15830) via two-stage removal with anterior panniculectomy. The requested CPT 15830 is not medically necessary for treatment of the patients medical condition. It would be medically necessary rather than cosmetic in nature if the removed skin has a history of recurrent infections, is necrotic, interferes with range of motion and blocks a body orifice. However, the mere presence of a pannus and/or its psychological or physical burden on the patient does not make its removal medically necessary. Given the lack of documented treatment or existence of recurrent rashes under the abdominal pannus the request for CPT 15830 is not supported as medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Overturned

A 32-year-old female enrollee requested maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18 and trisomy 13) for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Isolated fetal pyelectasis is well-established in the medical literature as an ultrasound marker associated with an increased risk of aneuploidy, specific trisomy 21. The American Congress of Obstetricians and Gynecologists (ACOG) list ultrasound markers associated with increased risk for aneuploidy as an accepted indication for offering NIPT, if a patient declines amniocentesis. Also, the fact that a woman is less 35 years of age is irrelevant once an ultrasound marker increasing the risk of aneuploidy is identified. Furthermore, NIPT is an amplified screening test and is appropriately offered to women at increased risk for aneuploidy, particularly trisomy 21, where the sensitivity for NIPT exceeds 99%. The validation of this test for high-risk populations has been established, and ACOG has endorsed its value in these situations for high-risk pregnancies. Given these factors, the services at issue were medically indicated. All told, the medical necessity of the maternal plasma cell-free fetal DNA sequencing for fetal aneuploidy detection for the detection of fetal aneuploidy (trisomy 21, trisomy 18 and trisomy 13) has been established in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy provided over a 2-1/2 month period for treatment of the enrollees depression.  Findings:  Two physician reviewers found that the patient was diagnosed with major depressive disorder, attention deficit hyperactivity disorder and generalized anxiety disorder. Her symptom complex consisted of anhedonia, guilt, interpersonal withdrawal, irritability, decreased libido and diminished occupational performance. In terms of psychiatric treatment, it appears that the patient was active in twice monthly outpatient psychotherapy. There was no documentation of more intensive therapeutic environments, such as partial hospitalization or residential program treatment. A remote history of acute psychiatric hospitalization was reported. The patient has reportedly undergone trials of multiple psychotropic medications including citalopram, sertraline, bupropion, venlafaxine, mirtazapine, trazodone, and oxcarbazepine. Psychopharmacotherapy had not achieved remission. Due to persistent affective symptomatologies, transcranial magnetic stimulation (TMS) therapy was recommended. The patient received TMS therapy over a 2-1/2 period. The Health Plan has denied coverage stating that TMS is investigational.  Although TMS is a newer treatment technology, the literature supporting TMS in terms of volume, quality and range of investigation continues to grow. The article by Schutter suggests that the efficacy of TMS may be greater than originally reported. In addition, George and colleagues have reported more conclusive findings in well-developed studies. Further, the demonstration of hippocampal neurogenesis in rats by Ueyama, a phenomenon commonly seen in psychotropic medication and electroconvulsive therapy, is representative of a promising expansion of the TMS research base. TMS is also endorsed by the American Psychiatric Association (APA) for use in the acute phase treatment of major depressive disorder. Thus, there is adequate peer-reviewed medical literature to support the safety and efficacy of TMS in well selected patients. However, the documentation provided on this patient did not describe any trials of evidence-based psychotherapies proven to be helpful in the treatment of depression. Moreover, trusted and well-established medication management and augmentative strategies commonly used in the treatment of major depressive disorder have not been exhausted. For these reasons, the TMS therapy at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the nerve testing (autonomic testing) for evaluation of the enrollees tachycardia. Findings:  All three physician reviewers found that this patient was complaining of palpitations during their office visit which prompted an ECG which did not reveal any ectopy. This was followed by a Holter monitor which is an appropriate cardiac test in the work-up of palpitations. This test revealed rare PVCs. However, it is unclear whether the patients symptoms correlated with these ectopic beats. The office visit note also mentioned shortness of breath and lightheadedness. The patients blood pressure in the office was normal but no orthostatic blood pressure levels were reported. There were no symptoms in the office notes which would support an indication to test the patients autonomic nervous system function. In patients with orthostatic symptoms, autonomic nervous system function is not indicated prior to orthostatic blood pressure testing in the office, at home blood pressure monitoring, a detailed history for possible causes of orthostatic intolerance and treating the patient with a high salt and fluid diet. Autonomic function testing is a specialized test that is reserved for patients after non-pharmacologic measures such as volume repletion and pharmacologic measures such as fludrocortisone have failed to improve symptoms. Final Result: The 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: Reviewer 1 is board certified in pediatrics with sub-specialty certification in pediatric cardiology and is actively practicing. Reviewers 2 and 3 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: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested for the medication Provigil for treatment of her multiple sclerosis (MS).  Findings:  Three physician reviewers found that there are multiple studies that demonstrate the benefit of Provigil for patients with multiple sclerosis (MS). In addition, this therapy is considered the standard-of-care by many MS specialists for treating fatigue in this patient population. Its use in this setting is supported by the medical literature cited above. In addition, this patient had previously failed a course of amantadine, making her an appropriate candidate for the use of Provigil.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 15-year-old female has requested approval for inpatient mental health services, or in the alternative, mental health partial hospitalization/day treatment program level of care services for treatment of her behavioral health issues.  Findings:  The physician reviewer found that a careful review of the facts in the records provided for review demonstrate that the patient was treated in RTC for an eating disorder, and at the time of admission, she is listed as being in remission. Therefore, she has certainly benefited from the treatment, and apparently sustained her gains. Additionally, her provider notes that her substance abuse has declined from polysubstance abuse to episodic marijuana abuse, which is also an improvement. This patient sustained traumatic brain injury (TBI) after being discharged home from the RTC treatment. She is described as becoming aware of her cognitive deficits and having difficulties keeping up in school. This is described as the acute stressor that has driven her depression as well as her suicidal and self-injurious behavior. According to the records, the patients main problem is sensitivity to stress with over-reactions and irritability. This is a common occurrence after TBI and is treatable with medications and behavior therapy, both of which should be available at the PHP level of care. The PHP level of care should safely and adequately provide the support and direction clinically indicated for this patient at this time. Therefore, the requested inpatient services mental health services are not medically necessary. However, the PHP/day treatment program level of care services is supported as medically necessary for treatment of this patients medical condition from the date at issue and forward.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400-100 mg tablets for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, Epclusa is recommended as first-line treatment for genotype 2 patients, based on clinical trials which showed superiority to Sovaldi with ribavirin, including in patients who have failed peg-interferon and ribavirin.  A delay in treatment may result in decreased survival.  All told, Epclusa 400-100 mg tablets are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: Upheld

The representative of a 62-year-old female enrollee has requested resumption of acute inpatient rehabilitation for treatment of the enrollee, who is status post cerebrovascular accident. Findings:  The physician reviewer found the patients functional status had plateaued. Treatment goals had been achieved and had even been exceeded with respect to ambulation. Therefore, additional acute inpatient rehabilitation beyond the date of service in question was not clinically indicated.  In order to qualify for continued acute inpatient rehabilitation services, an individual should be continuing to demonstrate significant and measurable progress toward stated goals. Once progress has plateaued or slowed to the point where further gains will be limited and/or slow to achieve, patients are generally discharged from acute inpatient rehabilitation and transitioned to a less intensive level of rehabilitation services. In this patients case, resumption of acute inpatient rehabilitation is not medically indicated.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested fractional laser for treatment of his hypertrophic scar on the lower lip.  Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), actinic keratosis is considered a precancerous lesion that requires treatment. The records indicate that treatment for this patients actinic keratosis caused a hypertrophic scar, which is an abnormal structure of the lip. While a scar is expected after any significant surgical excision, there is not adequate documentation to suggest that this patients scar is creating a functional or significant appearance deficit. The photographs provided do not support that there is significant scar hypertrophy. The treating provider notes that the scar has improved 60-70%. In addition, the patient is not documented to have undergone standard therapy except for one steroid treatment and the success or failure of these treatments is not adequately defined. Overall, there is insufficient documentation to demonstrate that the patient has a significant abnormal appearance to support the requested services as reconstructive in nature. In the absence of a clearly defined functional deficit or a significant abnormal appearance, the requested services are not reconstructive in nature and are not medically necessary for treatment of the patients medical condition.