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

A 47-year-old female enrollee has requested FAMILION genetic testing (CPT codes 83891, 83898, 83904, 83909, and 83912) for evaluation of her condition in order to rule out Brugada syndrome. Findings:  Two physician reviewers found that this patient has a paternal family history of early sudden cardiac death and has been symptomatic with unexplained syncope which resulted in significant head injury, suggesting a cardiac etiology. Indeed, given the nature of the event, she was initially fitted with an external vest type defibrillator which was then switched to a permanent internal cardio defibrillator. Subsequently, she underwent evaluation at the hereditary arrhythmia clinic with multi-lead resting and exercise ECG testing which showed some abnormalities suggestive of Brugada, but was non-diagnostic. There were also borderline QT abnormalities noted, especially during the exercise portion of the test as well. Her records do not provide any indication of ischemia or structural heart disease as an etiology for the syncope. As the surface ECG is not always particularly helpful in the specific diagnosis, genetic testing is a reasonable option in this symptomatic higher risk patient not only for determining the long-term prognosis and risk, but also the proper medical treatment. It will also help to ascertain if other first degree relatives need to be screened for the disorder as well. As reported in the scientific data, both the prognosis of the patient and pharmaceutical treatment (i.e. beta blockers or other anti-arrhythmic medications) has been shown to vary with the specific type of channelopathy caused by the genetic mutation. For instance, Zareba and colleagues concluded that, The genotype of the long QT syndrome influences the clinical course. Since this patient has an unexplained, and likely cardiac syncopal event which necessitated the placement of an internal defibrillator, along with subtle changes of possible Brugada or long QT on the ECG and at least some family history of sudden death in the absence of known structural or ischemic heart disease, the FAMILION genetic testing for an inherited channelopathy was a reasonable diagnostic option in this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested 12 weeks of Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three 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: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 36-year-old female enrollee has requested Botox injections for treatment of her chronic migraine. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services in this patients case.  This patient has a diagnosis of chronic migraine, with reported headaches greater than 15 days per month at baseline.  She has been on prior preventive medications, including antidepressants.  The patient reported significant benefit following Botox injections, with reduction of headaches by greater than 50%.  The medical literature indicates that Botox injections are effective for chronic migraine.  The current medical evidence has established the efficacy of Botox injections in this clinical setting.  All told, the requested Botox injections are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospitalization. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavior health condition.Findings: The documentation supports the medical necessity of the services at issue in this clinical setting. The records indicate that this patient was undergoing a formidable mental illness burden in context of multiple psychosocial stressors. The patients mood disorder was characterized as severe and complicated by anxious distress.  In both clinical practice and in the medical literature, anxiety ridden mood disorders are difficult to treat. The patient reported that she felt terrible and wished for death. The patient required two doses of anxiolytic medication, prescribed as needed within the previous 24-hour period.  The provider noted anxiety, depression and suicidal ideation, and articulated a reasonable rationale for continued hospitalization.  The attending provider recommended continued inpatient treatment as the patient remained symptomatic with the illness complex that prompted the admission.  The patient was engaged in active treatment and had completed three ECT treatments by the last covered day.  Due to the severity of the illness burden and considering that a premature discharge would be both unsafe and inadequate, it was medically indicated for the patient to remain in the hospital to assess the aftereffects of the fourth ECT treatment. This provided the opportunity for the providers to finalize the discharge plan, ensuring a safe decision consistent with good medical practice.  As such, the services in dispute were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Accordingly, inpatient services were medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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: Upheld

A 43-year-old female enrollee requested authorization and coverage for lumbar interbody fusion surgery.  Findings:  The physician reviewer found that the role of fusion in the treatment of low back pain remains a source of controversy. It is indicated in situations of demonstrated instability, for the treatment of scoliosis, and in cases of iatrogenic instability resulting from extensive decompression. Improvement can be expected with fusion when an established indication, such as spondylolisthesis, exists. However, patients with chronic low back pain experience less improvement. Diffuse low back pain without pathomorphological correlation or explainable functional deficit is not an indication for fusion. For non-radicular back pain, fusion is no more effective than intensive rehabilitation, and fusion is rarely indicated for routine discectomy.  Discography has been shown to have limitations as to reliability, with inconsistent post-surgical outcomes.  In this patients case, there is a lack of documentation of the presence of instability at the L5-S1 level. The submitted documentation fails to establish the medical necessity of the requested procedure.  All told, the requested lumbar interbody fusion surgery is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the requested treatment is medically necessary and is considered the standard of care for the treatment of patients with chronic hepatitis C. In this case, the patient presents with advanced stage disease as he has progressed to cirrhosis. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America Immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. This patient has evidence of cirrhosis. Therefore, per the national guidelines Harvoni for 12 weeks is medically necessary. 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 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

A 45-year-old female enrollee has requested bilateral reduction and extended panniculectomy and abdominoplasty  for treatment of her excess skin and fat.  Findings:  The physician reviewer found that based on the records provided, the patients condition constitutes an abnormal structure of the body. Given the previous authorization for surgery and records from the treating surgeon indicating macromastia symptoms dating back to 2008, there is evidence supporting an abnormal structure as the patients macromastia is documented to cause her painful symptoms. Further, breast reduction surgery is effective in relieving the symptoms related to large breasts such as back pain, neck pain, skin breakdown, when these symptoms are present. To further delineate this group of patients, a Schnur scale was developed to relate the amount of breast tissue removed to preoperative body mass surface area as a means of differentiating cosmetic from reconstructive medically necessary breast reduction surgery prior to surgery. This also makes intuitive sense because if the surgeon removes a small amount of tissue it is highly unlikely that would have any effect on back pain. In general, as the amount removed is increased, the procedure shifts from a cosmetic procedure to a medically necessary and reconstructive procedure. The Schnur scale accounts for varying body types by relating the amount removed to body surface area of the individual patient. With regard to this patient, the removal of over 600 grams of tissue from one breast meets these criteria. In addition, the breast reduction surgery was performed to improve function by relieving the patients back and neck pain as well shoulder bra strap grooving. Despite the operative report listing sagging breasts as the indication for breast surgery, the removal of more than 600 gm from a breast indicates this procedure was performed with greater clinical justifications. The treatment for sagging breasts is just a breast lift (mastopexy) with little or no breast tissue removal. Considering the amount of tissue removed from each breast and the abdomen, it is likely that the surgery at issue improved the patients appearance however this was not the primary goal of the procedures.
Appeal type: Experimental/Investigational
Decision: Overturned

A 45-year-old female enrollee requested positron emission tomography (PET) scan for medical evaluation of her follicular lymphoma.  Findings:  Two physician reviewers found that there is support in the medical literature for the requested services in this clinical setting. According to Trotman and colleagues, PET-CT rather than contrast enhanced CT scanning should be considered as a new standard for response assessment of follicular lymphoma in clinical practice, and could help guide response adapted therapy.  In this particular case, the patient has developed symptoms. Her fatigue and weight loss are B symptoms and she has already had a CT scan. Furthermore, she has developed an elevated lactate dehydrogenase (LDH) level which can be one of the indicators of recurrent disease. In conclusion, given the patients symptoms of fatigue and weight loss and the medical literature cited above, the requested PET scan is likely to be more beneficial for evaluation than standard medical therapy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) guidelines, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. ASAM criteria focuses on six dimensions to determine the appropriate level of care including: (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 framework, this patient met the medical necessity criteria for RTC services. The patient was placed on a detoxification protocol due to her imminent withdrawal and the associated risks. Given her heavy use of opiates and sedatives, the patient remained at elevated risk for relapse. She self-harmed while in RTC, which required intermittent monitoring. The patients medical history includes seizures, which places her at risk for recurrent seizures during withdrawal. The provider noted the patient has comorbid GAD. The patient has demonstrated a willingness to change, but has had difficulty finding successful coping strategies. The use of head banging as a coping strategy needs to be replaced with effective coping strategies. In addition, despite seizures, blackouts, and seizures, the patient has continued to use. This suggests that the patient has a strong pull to continue to use, which elevates her risk of relapse. The patients mother has been generally supportive but is noted to be unreliable as a source of support. Lower levels of care have thus far been inadequate support for her as evidenced by her continued use. The patient required a safe and stable living environment in order to develop her recovery skills. The records support that the patient qualified for ASAM Level III treatment, similar to what patient received at the RTC facility. Given the severity of the patients illness, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee has requested authorization and coverage for future positron emission tomography (PET) scans for evaluation of the enrollees pancreatic cancer.  Findings:  Three physician reviewers found that the patient was found to have a left ovarian tumor compatible with mucinous cyst adenocarcinoma, probably pancreatic in origin. An initial computed tomography (CT) scan failed to detect the pancreatic tumor as well as the patients intraperitoneal and omental metastases. A subsequent positron emission tomography/computed tomography (PET/CT) was positive for the tumor. Thus, staging and therapeutic decisions have depended on the PET/CT results particularly in light of the understatement of disease by conventional CT. The patient has requested authorization and coverage for future PET/CT scans for follow-up.  However, the Health Plan has denied the request stating there is no literature supporting the use of PET/CT to prolong survival and therefore its use in this clinical setting is investigational.  In this patients case, conventional CT has proven to have some limitations in efficacy as the original pancreatic tumor was not visualized and the degree of intraperitoneal metastases was understated. By contrast, the physiologic capabilities of PET/CT have been illustrated to be of benefit in this patients disease as PET/CT has allowed not only a more detailed diagnosis and staging but also allows for evaluation of treatment success due to the physiologic properties of PET imaging. While it is unresolved whether survival is prolonged by the use of PET imaging in pancreatic cancer, given that PET/CT has been a valuable diagnostic tool in evaluating this patient when CT alone was inadequate, the requested PET/CT is more likely to continue to reveal the tumors PET avid response.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested a panniculectomy for treatment of her tinea corporis under pannus.  Findings:  The physician reviewer found that this patient presents status post bariatric surgery, with documented weight that has been stable for at least six months. She has a BMI of less than 30 and it has been longer than 18 months since her bariatric procedure. Her records demonstrate that she presents with at least three months of chronic rashes unresponsive to conservative treatment. Photographs of the patient show redundant supraumiblical and infraumbilical tissue. The pannus hangs over the upper edge of the pubic bone but does not cover the escutcheon. Therefore all of the Health Plans coverage criteria are met for a panniculectomy, but an abdominoplasty would be cosmetic and therefore not medically necessary. This outcome is also consistent with the guidelines published by the American Society of Plastic Surgeons (ASPS). Applying these criteria, the requested panniculectomy will improve this patients function by removing tissue that is recurrently infected and is therefore reconstructive in nature. In addition, the photographs clearly show the pannus hangs over the upper edge of the pubic bone. From this, it appears that the requested surgery is being performed to create a normal appearance to the extent possible and is likely to result in more than a minimal improvement in appearance as well as function. For these reasons, I have determined that the requested panniculectomy is reconstructive in nature and medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for the cellular function assay with stimulation test involving tumor necrosis factor (TNF) antagonists drug level and neutralizing antibody for evaluation of the enrollees Crohns disease. Findings: Two of the three physician reviewers found that Simultaneous measurement of serum infliximab level and infliximab antibody titers prior to administration of regular infliximab dose significantly increases the diagnostic accuracy for the therapeutic decision in patients uncertainly responding to the therapy. According to a study, patients who had poor responses and sub-therapeutic infliximab trough levels had an improved response to dose intensification. Tailoring individual infliximab treatments based on infliximab trough levels is supported in the medical literature and widely used for patients with Crohns disease. Levels are generally checked before increasing the dose or changing frequency and helps to decide if the change in dose or frequency of the drug will make a positive impact on the patients health outcome. Final Result: The 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: Reviewers 1 and 3 are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and are actively practicing. Reviewer 2 is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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

A thirty-three year-old female diagnosed with right breast cancer, high-grade, poorly differentiated probably infiltrating ductal is requesting authorization of a PET scan.  Reviewers Findings:  The reviewing physician found that the PET scan has been shown to be more sensitive, specific, accurate, and have better positive and negative predictive values than conventional imaging for detecting local recurrence or distant metastases.  The reviewing physician found that the Health Plan denial should be overturned.