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 Gene Assay. Findings:  Three physician reviewers found this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Thus, the medical evidence does not support the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma Gene Assay was not likely to have been more efficacious than other methods of evaluating this patient. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for magnetic resonance-guided high intensity focused ultrasound (MRgFUS). Findings:  The physician reviewer found that  Osteoid osteoma is a small, painful benign bone lesion that accounts for 10% of all bone tumors.  Osteoid osteomas may resolve spontaneously but the process can take several years. For many patients, the pain can be severe, with significant impact on health related quality of life, including effects on physical, emotional, social, and role functioning. Early pain management interventions can reduce pain duration and pain-related disability. Minimally invasive, percutaneous thermal ablation techniques, such as computed tomography (CT)-guided radiofrequency (RF) ablation, laser ablation, and cryoablation are the current standard of care treatment for peripheral bone lesions. MRgFUS is a thermal treatment modality that uses high power ultrasonic energy to thermally coagulate tissues in the body.  While there is current literature to support its efficacy in treating osteoid osteoma refractory to medical therapy, there is still a lack of data to show that this modality is more effective than the standard of care treatment. Therefore, MRgFUS is not likely to more efficacious than the available options for treatment of this patients medical condition. Final Result: Two of the three he reviewers determined that the requested procedure 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 & 3 are board certified in interventional radiology and 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: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for treatment with a wound care specialist. The critical aspects of the wound healing mechanism and host physiological status in patients with diabetes necessitate the selection of an appropriate treatment strategy based on the complexity and type of wound. In addition to systemic antibiotics and surgical intervention, wound care is considered an important component of diabetic foot ulcer management (Kavitha, et al.). This patient has significant foot ulcer with osteomyelitis and peripheral vascular disease. Wound clinic and specialist have access to advanced dressings, hyperbaric oxygen, and skills that are necessary to heal a wound in high-risk situations. Continuity of care by a wound specialist in a multidisciplinary context is standard of care for diabetic foot ulcers and leads to improved limb salvage (Flores, et al.). Although the patient has home health, a visiting nurse cannot perform continued wound care without direction from a physician. In addition, the patient requires weekly ulcer debridement, which must be performed by a wound specialist physician (Blume and Wu). The physician reviewer found that  the requested treatment with a wound care specialist is medically necessary for management of this patients diabetic foot ulcers. 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.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested bilateral capsulectomy and the removal of saline breast implants for treatment of her status post breast implant placement.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The initial breast augmentation was a cosmetic surgery.  If there is painful symptomatic grade IV capsular contracture and/or rupture of an implant, implant removal with capsulectomy would be considered medically necessary.  However, in this patients case, the submitted photographs support a grade III contracture on the right, but only a grade I or II contracture on the left.  Lateral displacement of the left implant by the seat belt is not equal to a high-grade capsular contracture.  There is inadequate documentation to assign a grade IV to the right breast.  Given the absence of grade IV contractures, infection, implant extrusion, breast disease in proximity to the implants, or rupture of implants, the medical necessity of the requested services has not been established.  This, the requested bilateral capsulectomy and the removal of saline breast implants are not medically indicated in this clinical setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested an immune cell function assay for evaluation of the enrollees behavioral regression, strep pneumonia, cough, and autoimmune disease, not elsewhere classified. Three physician reviewers found that according to the medical literature, certain entities such as PANS and pediatric neuropsychiatric disorders after streptococcus infection (PANDAS) have been described as autoimmune disorders. However, the evidence that entities such as PANDAS are autoimmune has not been definitively established. PANS is a symptom complex whereby draft criteria have been established by experts to describe the entity. Based upon the available evidence-based literature, PANS is an area of ongoing research without defined standards of care for laboratory diagnosis or treatment where even the diagnostic criteria are the subject of study. A set of published expert recommendations for the clinical evaluation of pediatric patients with PANS did not include immune cell function assay as part of the published guidelines for immunology work-up for this condition. Based upon the evidence-based literature reviewed, the immune function assay was not likely to be more beneficial for evaluation of this patients medical condition than any available standard testing.  Final Result:  Three 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: One reviewer is board certified in pediatrics and pediatric critical care and is actively practicing. One reviewer is board certified in internal medicine, rheumatology, and allergy and immunology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Qsymia 7.5-46 mg extended release (ER) capsules for treatment of the enrollees migraine and obesity.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Qsymia is not indicated for the treatment of migraine. Qsymia is U.S. Food and Drug Administration (FDA) approved for the treatment of obesity. Qsymia for the treatment of obesity is not medically necessary for this patient. There is a lack of documentation showing that the patient has tried and failed weight loss through an exercise program. Therefore, the request for Qsymia 7.5-46 mg ER capsules is not medically necessary.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old female enrollee has requested for psychoanalysis on an outpatient basis four times a week for treatment of the enrollees eating disorder and depression.  Findings:  The physician reviewer found that there is no evidence in the peer-reviewed literature that intensive psychoanalysis is more effective than weekly psychoanalysis for the treatment of OCD or eating disorder. That being said, given the length of time the patient had been in therapy four times per week, tapering the sessions over a period of several weeks was clinically warranted.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity-modulated radiation therapy (IMRT) (CPT 77263, 77334, 77338, 77011, 77301, 77370, 77280, 77300, 77336, 77470, G6015, G6002, and 77427). Betarbet and Blalock describe keloids as abnormal scars that may cause patients significant emotional and physical distress if inadequately treated. The authors further note that common treatment methods include steroids and radiation therapy. Lin and colleagues note that electron beam radiotherapy is typically utilized in the treatment of keloids to allow for a high surface dose and sharp dose fall off to tissues beneath the scar. However, electrons are typically not used on curved surfaces due to the dose distribution and dependency on the distance from the gantry to the skin, resulting in large amounts of dose heterogeneity. In this case, the patients radiation plan notes a large area of treatment over a curved surface. In this clinical setting, given the size and anatomic location of the patients keloid, the requested service is medically indicated to achieve a uniform dose distribution throughout the lesion treated while still sparing the underlying structures. Therefore, IMRT (CPT 77263, 77334, 77338, 77011, 77301, 77370, 77280, 77300, 77336, 77470, G6015, G6002, and 77427) is 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing (genetic testing) rendered on 5/17/17. Final Result: Two of the three reviewers determined that there is sufficient support for Guardant360 testing in this clinical setting. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network NSCLC Guidelines Panel strongly advises 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 NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. As such, molecular profiling such as with Guardant360 was 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 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:  Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and hematology. 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

The parent of an eight-year-old male has requested 20 hours per week of applied behavioral analysis (ABA) services and 8 hours per month of supervision for treatment of autism.  Findings:  The physician reviewer found that review of the submitted evidence demonstrates the patient has had multiple evaluations that independently noted behaviors consistent with autism spectrum disorder. ABA therapy has been shown to be effective in treating behaviors associated with autism spectrum disorder. The scientific literature demonstrates that treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. In addition, studies have shown that ABA methods continue to result in positive outcomes with individuals with autism and intellectual disability (Grey, et al.). Evidence-based studies also noted improvement of function in older children with autism spectrum disorders using intense ABA interventions (Granpeesheh, et al.) The goals for older children often are to identify and remediate particular deficits. The behaviors in this patient that require treatment include maladaptive behaviors of communication, noncompliance, tantrums and self-injurious behaviors. There is also the need to increase functional life skills as well as social and language skills. ABA therapy is an appropriate modality to address these concerns. Thus, ABA therapy is medically necessary for this patient at a frequency of 20 hours per week of applied behavioral analysis (ABA) services and 8 hours per month of supervision.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for an electric scooter for treatment of her osteoarthritis of the right knee. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records indicate that the patient has a decreased subjective tolerance to ambulation, but is otherwise an independent community ambulator without an assistive device. The patient does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices, such as the walker which was proposed in rehabilitation medicine clinic.  Physical activity and exercise, moreover, are generally appropriate and recommended in the setting of obesity and for general musculoskeletal health.  A power mobility device such as an electric scooter is not medically appropriate for this patient.  All told, the requested electric scooter is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 parents of a 10-year-old male have requested growth hormone (GH) therapy with Humatrope for treatment of idiopathic short stature.    Findings:  The physician reviewer found that it would appear from the information included in the record the patient will have a delayed adolescence but will eventually reach a normal adult height. His adult height prediction excludes him from coverage for GH therapy on the basis of idiopathic short stature according to the July 2003 FDA guidelines.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for carotid ultrasound test (carotid duplex scan).  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an increased cardiovascular risk but history of carotid disease, no documented symptoms suggestive of neurologic disease, no focal neurologic findings on physical examination and no documented carotid bruits. In this circumstance of no symptoms or findings suspicious for carotid disease, a carotid ultrasound is not considered standard accepted practice in the medical community.  Current guidelines do not recommend screening carotid ultrasound in this setting. Therefore, carotid ultrasound test (carotid duplex scan) was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were 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 internal medicine with sub-specialty certification in cardiovascular disease 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 An enrollee has requested authorization and coverage for Somatuline Depot (lanreotide) 120 mg/0.5 mL.  Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature demonstrate the medical necessity of the requested medication. The patient presents with multiple metastatic carcinoid lesions. She has undergone resection of multiple lesions in the liver, jejunum, mesentery and lymph nodes. There are persistent lesions in liver. The patient has fecal urgency and pancreatic insufficiency. There is adequate medical literature demonstrating the efficacy and benefits of lanreotide in patients with neuroendocrine tumors and carcinoid syndrome . Somatuline Depot is highly effective in controlling the symptoms associated with carcinoid tumors  For patients who are symptomatic from carcinoid syndrome, initiating treatment with a somatostatin analog is recommended. Somatuline Depot is a long acting analog that is administered every four weeks, and it has been beneficial for this patients management for many years. Lack of treatment places the patient at risk for recurrence and further metastatic disease that can lead to carcinoid crisis. Carcinoid crisis is a life-threatening form of carcinoid syndrome that results from the release of an overwhelming amount of biologically active compounds from the tumor; it may be triggered by tumor manipulation (eg, biopsy, embolization, surgery) or anesthesia, and occurs mostly in patients with markedly elevated serum serotonin or urine 5-hydroxyindoleacetic acid (5-HIAA) . Therefore, Somatuline Depot 120 mg/0.5 mL has been established as medically necessary for treatment of the patients differentiated carcinoid tumor.  Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 62-year-old female enrollee has requested  Juxtapid (lomitapide) 5 mg capsule for treatment of her hypercholesterolemia.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. Based on the medical records provided, the patient has coronary disease and several coronary risk factors including marked hyperlipidemia. However, there is no documentation to support homozygous familial hypercholesterolemia, a rare disorder effecting only one in one million births, since there is no documentation of LDL levels greater than 500 mg/dl, similar hyperlipidemia in parents, xanthomatosis in childhood, or supravalvular aortic stenosis from plaque accumulation. Further, Juxtapid (lomitapide) was approved by the U.S. Food and Drug Administration (FDA) only for the treatment of homozygous familial hypercholesterolemia.  In addition, its use is restricted since therapy is associated with elevated liver aminotransferase levels in roughly 40% of patients and hepatic fat accumulation in roughly 8% of patients (Cuchel, et al (2007)). Moreover, there is a lack of trials in the peer-reviewed literature to support that treatment with Juxtapid improves cardiac outcome.  This is important since some other novel lipid agents have not been associated with improved cardiac outcomes even though they have been shown to significantly reduce lipid levels (Kastelein, et al). For the reasons provided, the medical necessity of the requested medication has not been established in this patients case.