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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.Findings:  Three physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her 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, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast. A researcher noted that breast tomosynthesis technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. Other researchers concluded that, addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 63-year-old female enrollee has requested Botox injections for treatment of her migraine.  Findings:  Three physician reviewers found that this patients long-term history of disabling and recurrent headaches, occurring nearly daily with some mild photophobia and nausea, which respond to triptans, is consistent with migraine.  Additionally, the frequency is consistent with chronic migraine.  There is documented failure of several preventive agents.  Given her asthma diagnosis, beta blockers are contraindicated.  The medical evidence supports Botox injections in this clinical setting.  In this patients case, Botox injections provided on said date were likely to have been more effective than other available treatment options.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a computed tomography (CT) scan of the heart. Findings:  Three physician reviewers found that based on the records provided for review, this patient presents with some coronary risk but no symptoms or objective findings suggestive of coronary ischemia. In this circumstance, guidelines for evaluation and management of cardiovascular risk are available and do not recommend routine screening with cardiac CT scanning. Moreover, cardiovascular outcomes have not been shown to be incrementally improved from treatment based on routine screening cardiac CT scan results compared to treatment based on standard clinical risk profiling and standard lipid measurements alone. Specific guidelines endorsed by several national organizations also do not consider a screening CT scan appropriate in this setting. All told, the requested CT scan of the heart is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.For these reasons, the requested diagnostic procedure is not likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Final Result: The reviewers determined that the requested diagnostic procedure is not likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for magnetic resonance imaging (MRI) of the lumbar spine and pelvis (procedure codes 72148 and 72195). The Health Plan denied the request and reported the services at issue were not medically necessary for the evaluation of this patient. At issue in this case is whether MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were medically necessary for the evaluation of the patients medical condition. The American College of Radiology appropriateness criteria indicates that MRI of the lumbar spine is usually not appropriate for acute, subacute, or chronic uncomplicated low back or radiculopathy without red flags or prior management. In this case, there was no documentation of any red flags, such as neurological compromise. There was no indication of how many physical therapy sessions the patient had or the results of those sessions. There was also no documentation of a repeat ultrasound of the left ovary indicating a need for an immediate pelvic MRI. The clinical presentation of left sciatica does not support the medical necessity of a pelvic MRI. Therefore, MRI of the lumbar spine and pelvis (procedure codes 72148 and 72195) were not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services were 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 radiology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing. While gene expression profile (GEP) testing has been shown to accurately identify risk of metastasis for patients with cutaneous melanoma, there is a lack of  consensus on how this affects the treatment plan for patients. GEP testing is not considered routine standard of care and is not currently recommended under National Comprehensive Cancer Network (NCCN) guidelines. There is a lack of medical literature supporting its use for the evaluation of patients with thin melanomas. In this case, the course of treatment for this patient would not change based on the results of the GEP testing, as the recommended course of treatment would still be a wide local excision with follow-up skin surveillance and possible sentinel lymph node biopsy. Therefore, the DecisionDx-Melanoma testing was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma testing at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was 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 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 Harvoni for treatment of her 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. The guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks. This is based on the SYNERGY trial for Harvoni. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy.  For these reasons, treatment of the patients hepatitis C at this time is indicated, and treatment with Harvoni is medically necessary in this case. 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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 4aFindings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment naive genotype 4 patients, based on the ASTRAL-1 trial, which showed 100% cure rate. Delay in treatment may result in decreased survival.  For these reasons, Epclusa 400-100 mg 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Foundation One gene testing for evaluation the enrollees metastatic melanoma.Findings:  Two physician reviewers found that diagnostic features used to direct treatment and prognosis of melanoma include location of primary, stage of disease, tumor thickness, ulceration and mitotic rate. Initial evaluation of metastatic melanoma also includes determination of the lactate dehydrogenase level and molecular profiling. Molecular profiling has become more relevant with the development of several targeted therapies. Recent data has demonstrated that patients with specific mutations in BRAF and KIT bare tumors more susceptibility to BRAF inhibitors and tyrosine kinase inhibitors, respectively. According to the National Comprehensive Cancer Network (NCCN) guidelines, genetic analysis is described as screening for mutations in BRAF, and in the appropriate clinical setting, C-KIT. Thus, current guidelines support tumor molecular profiling as part of clinical care and treatment for metastatic melanoma. The information provided eliminated the treatment option of a BRAF inhibitor, but demonstrates a potential role for therapy based on his KIT mutation. Final Result: Two reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and 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

The parents of a five-month-old female enrollee have requested Synagis for the treatment of the enrollees risk of respiratory syncytial virus (RSV) infection. Findings:  Two physician reviewers found that although there is an older sibling in the home attending preschool and the pediatrician ordered Synagis therapy for the patient, she does not meet criteria for RSV prophylaxis. There are no indications for treatment with Synagis, and it is not the standard within the pediatric community to do so.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old female enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urinary urgency and frequency nocturia.  Findings:  Two physician reviewers found there is documentation that this patient has been treated with and failed to improve with adequate trials of medications including Toviaz and Vesicare. In addition, the patients nocturia and urinary frequency improved with PTNS treatment. The peer-reviewed medical literature supports the use of PTNS in this clinical setting. All told, the PTNS at issue was and is likely to have been more beneficial for treatment of this patients urinary symptoms when compared to standard available therapies.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient has not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  In reviewing the clinical documentation, the partial hospitalization services remain medically indicated and consistent with good medical practice.  Further, the services are reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, partial hospitalization program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a DecisionDx-Melanoma test. The use of gene expression profiling (GEP) testing according to specific American Joint Committee on Cancer (AJCC) melanoma stage, before or after sentinel lymph node biopsy (SLNB), requires further prospective investigation in large, contemporary data sets of unselected patients. Prognostic GEP testing to differentiate melanomas at low-risk versus high-risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in melanoma at this stage and a higher proportion of false-positive results, GEP testing should not guide clinical decision-making in this subgroup. Therefore, DecisionDx-Melanoma test was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma test at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 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: Upheld

The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for clinically managed high-intensity residential services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Applying the ASAM criteria, the patient was not in withdrawal or at risk for acute or subacute withdrawal. The records suggest that the patient could have transitioned to a sober living environment, which would have provided safety and support for relapse prevention with regular daytime participation in a lower level of care. For these reasons, the RTC services at issue were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 psychiatry with expertise in addiction medicine 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 13-year-old female enrollee has requested applied behavioral analysis (ABA) therapy for treatment of her autism. Findings:  The physician reviewer found that applied behavioral analysis has been shown to be effective in treating behaviors associated with autism spectrum disorder. Treatments such as ABA which are based on operant principles of learning are more effective in reducing maladaptive behaviors than alternative treatments. Treatment intensity may play an important role and ABA therapy must be implemented at a sufficient intensity in order to provide optimal outcomes (Granpeesheh, et al.). Although the most significant gains are made after one year of ABA therapy when compared to controls, further gains have been noted in subsequent years of therapy (Sallows, et al.). Additionally, many studies have noted improvement of functional skills in older children with autism spectrum disorders, with the use of intensive ABA therapy (Granpeesheh, et al.). Skill deficits that have benefitted from ABA include language, social functioning, independent living skills and challenging behaviors. Given this patients documented deficits in self-help skills, community safety, and language and communication as well as the presence of maladaptive behaviors, continued ABA therapy at the requested frequency is medically reasonable and appropriate.