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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (molecular profiling). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung cancer.Findings:  Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that affect therapy selection. The National Comprehensive Cancer Network guidelines for non-small cell lung cancer endorses 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 for the improvement of care of patients with non-small cell lung cancer. 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. All told, the gene test (molecular profiling) was likely to have been of greater benefit than the other standard treatment modalities available for the evaluation of this patients medical condition.Final Result: Two of the three reviewers determined that 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 internal medicine with sub-specialty certification in medical oncology 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: Upheld

The patient is a 48-year-old male with multiple medical problems. He desires gastric bypass surgery. The patient has a history of deep vein thrombosis/pulmonary embolism (DVT/PE) in June 2004 following a fracture in his leg. He was treated with six months of anticoagulation therapy. The patient has no prior or family history of hypercoagulable problems. He now desires a prophylactic IVC filter placement prior to bariatric surgery. The Health Plan has denied coverage for the requested procedure on the basis that it is not medically necessary. The patient has undergone standard treatment of DVT/PE. It appears he no longer requires Coumadin therapy. There are no indications for prophylactic IVC placement at the present time. The patient has no prior history or family history of a hypercoagulable state. Placement of an IVC filter will not have any impact on DVT formation. The only potential benefit is to decrease occurrence of pulmonary embolism. Given the patients obesity, prior DVT, and sedentary lifestyle, he is at an increased risk for DVT in the perioperative period. The standard of care for patients such as this patient is low dose Heparin or low molecular weight Heparin perioperatively, pneumatic compression stockings perioperatively, and a screening duplex scan of the legs for DVT formation. There is no evidence that prophylactic IVC placement prior to gastric bypass surgery will be beneficial for this patient. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The enrollee has requested authorization and coverage for Bydureon BCise. Findings:  The physician reviewer found that the medication requested is medically necessary. The patient has a diagnosis of type 2 diabetes. The patient was prescribed Bydureon BCise for controlling his postprandial blood sugars. Glucagon-like peptide-1 (GLP-1) agonists like Bydureon are U.S. Food and Drug Administration (FDA) approved for use in type 2 diabetes. Per the American Diabetes Association (ADA), glucagon-like peptide-1 receptor agonists may help patients meet their blood glucose levels as an adjunctive medication. The patient was prescribed basal insulin therapy, metformin therapy, and as an adjunctive medication, Bydureon to aid in controlling his postprandial blood sugars. Based on current literature, Bydureon therapy as an adjunctive therapy is medically necessary to treat type 2 diabetes patients in helping them meet their glucose goals. Therefore, the request for Bydureon BCise for the management of the patients type 2 diabetes 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 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 42-year-old male enrollee requested Norco for medical treatment of his pain.  Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose opiates may also cause adverse outcomes.  All told, Norco is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prothrombin G20210A (Factor II) mutation testing.Findings: Two of the three physician reviewers found that the prothrombin G20210A (Factor II) mutation testing was likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment. Individuals who are heterozygous for the G20210A mutation in prothrombin are at increased risk for blood clots, with an estimated 2-4 times increased risk for venous thrombosis. Prothrombin thrombophilia is also associated with a somewhat increased risk of pregnancy loss. Such thrombophilia may also increase the risk of other complications during pregnancy, including pregnancy-induced high blood pressure (preeclampsia), slow fetal growth, and early separation of the placenta from the uterine wall (placental abruption). As this patient was known to be at 50% risk for having inherited this mutation, testing was warranted, as it will impact the patients medical management in the near future, if not now. Under these circumstances, the prothrombin G20210A (Factor II) mutation testing performed for the patient was likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the prothrombin G20210A (Factor II) mutation testing was likely to be more beneficial than any other available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics and in medical genetics and genomics and is actively practicing. Physician reviewer 2 is board certified in pediatrics and in medical genetics and genomics and is actively practicing. Physician reviewer 3 is board certified in medical genetics and genomics 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees risk of coronary artery disease. Findings:  The 3 physician reviewers found that the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this circumstance, guidelines for the management of cardiac risk have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Therefore, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld

A 44-year-old male enrollee has requested an MRI of the right upper extremity for an evaluation of his right shoulder pain. Findings:  The physician reviewer found that the peer-reviewed literature supports the use of conservative measures prior to advanced imaging in patients with uncomplicated shoulder pain. The Australian Acute Musculoskeletal Pain Guidelines Group noted that imaging is not necessary unless there are alerting features of serious conditions. They reported that in the absence of alerting features, the diagnostic utility of imaging is minimal, and the results are unlikely to improve management. This patient presented with right shoulder pain and underwent a shoulder MRI the same day as his initial visit with his physician.  There was no clinical concern of infection or metastatic disease. Following the published guidelines, this patient should have undergone conservative therapy prior to MRI.   MRIs may be beneficial in differentiating chronic impingement from tears of the rotator cuff when a surgical approach is being considered, diagnosis is unclear or clinical examination is limited. Per the submitted documentation, this patient was not being considered for surgery, the diagnosis was not unclear and the clinical examination was not limited.  In this patients case, MRI of the right upper extremity was not medically indicated.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for occupational therapy services once a week. At issue in this case is whether occupational therapy services once a week are medically necessary for treatment of the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions. Regarding the evaluation and management of a child with autism spectrum disorder, researchers reported that treatment involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies. The patient was noted to have significant delays in her ability to perform activities of daily living and sensory testing. She requires ongoing occupational therapy to address significant delays in her ability to perform activities of daily living. The record shows that the patient has made progress in therapy, as she has met several goals. The medical evidence supports the requested services in this clinical setting. Therefore, occupational therapy services once a week are medically necessary to promote physical and mental health and efficiency, and to correct or ameliorate the physical or behavioral condition of the patients impaired visual/motor coordination, poor fine motor skills, and sensory difficulties.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 neurology with special qualification in child 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: Experimental/Investigational
Decision: Upheld

A 31-year-old male enrollee has requested LINX Reflux Management System for treatment of his severe gastroesophageal reflux disease (GERD). Findings:  Three physician reviewers found that LINX Reflux Management System (LINX) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of medical literature that compares the efficacy of LINX with other GERD treatment modalities such as Nissen fundoplication. Moreover, follow-up studies are needed to assess the long-term safety of LINX Reflux Management System. Although LINX holds future promise for treatment of a select GERD population, the procedure is not considered standard of care for GERD therapy and is not likely to be superior to other available treatment options.  For the reasons provided above, the requested LINX Reflux Management System is not likely to be more beneficial for treatment of the patients medical condition than other modalities.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patients parent has requested authorization and coverage for Surestep supramalleolar orthosis (SMO) (HCPCS code L1907 x two). Lee and colleagues report that a custom molded ankle orthosis with hinged joints potentially offers better control over the subtalar joint and the ankle joint during lateral cutting movements, due to total contact design and increase in material strength. In this case, the records note that the patient has tried and failed an off-the-shelf model of orthotics. Given that current medical literature supports  custom-made orthosis as more effective than off-the-shelf models at controlling medial lateral movement of the ankle during gait, the requested equipment is medically indicated. Therefore, Surestep SMO (HCPCS code L1907 x two) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 79-year-old man with a history of depression and bipolar affective disorder. The patient was admitted to an acute inpatient psychiatric hospital in May 2003 after experiencing increasing depression. At the time of admission, it was noted the patient was unable to care for himself and exhibited feelings of hopelessness and helplessness, severe anhedonia, decreased interest, and impaired judgment. The patient began treatment with antidepressants, psychostimulants, and a mood stabilizer. The patient continued to receive acute inpatient psychiatric treatment until 7/31/03. The Health Plan indicates that this level of care was not required after 7/9/03.The submitted records clearly indicate the patient was depressed during the period in question. The patients first euthymic day was not until 7/29/03. Given the patients initial presentation and ongoing depression without significant improvement, continued hospitalization was required. The documented evidence demonstrates that the patients entire stay was medically indicated. Therefore, I have determined that the services at issue were medically necessary. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. The U.S. Food and Drug Administration (FDA) has not approved the DecisionDx-Melanoma gene expression profiling (GEP) test for the staging or treatment of patients with melanoma. In addition, there is a paucity of consensus or current medical literature to demonstrate the clinical utility, appropriate use, or improved outcomes with use of the DecisionDx-Melanoma test for patients with melanoma. The National Comprehensive Cancer Network (NCCN) does not recommend routine use of the DecisionDx-Melanoma assay to help direct treatment, thus the information yielded with this test would not change the patients outcome or treatment. Furthermore, the American Academy of Dermatology (AAD) guidelines have not reported benefits with use of the DecisionDx-Melanoma test in the evaluation and treatment of patients with melanoma. The standard of care for this patient included a wide local excision and then periodic follow-up skin examination. All told, the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 25-year-old female enrollee requested authorization and coverage of gastric bypass surgery. The Health Plan denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees morbid obesity.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested procedure is medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 64-year-old male diagnosed with multiple myeloma that developed compression fractures of the thoracic and lumbar spine. He underwent three separate kyphoplasty procedures in April 2006, April 2006 and May 2006 which he indicates provided relief of his symptoms. The operative reports from April 2006 indicate an assistant or co-surgeon was utilized for these procedures. The Health Plan denied the patients request for reimbursement of the assistant surgeons charges based upon their determination that the services were not medically necessary.An assistant surgeon is defined as a physician who actively assists the operating surgeon in the performance of a surgical procedure. In this situation, one physician is acting as the surgeon and the other is acting under the direct supervision of the operating physician. In determining the need for an assistant surgeon, consideration is given to the complexity of the procedure and the condition of the patient. Kyphoplasty is typically performed by a single operating surgeon without an assistant. The procedure in this instance was not of sufficient complexity to require the use of an assistant surgeon. Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 56-year-old female with a 44-year history of migraine headaches, which affect her almost 15 days per month. The patient reports being bedridden for at least two days per month. The patient was also involved in a motor vehicle accident in 1996 with resultant cognitive deficits prohibiting the use of preventative treatments such as Topamax, Depakote, and Inderal. She is using Imitrex as an abortive treatment with some benefit, as well as Effexor for depression.The patient underwent Botox injections on 6/2/04 with significant relief from her migraines for approximately a three-month period. The injections were repeated on 9/7/04. The patient has reduced her usage of her daily pain medications secondary to relief from Botox injections. She is seeking authorization and coverage for further Botox injections.The patients severe migraine headaches and organic brain syndrome warrants the use of Botox injections for treatment of her migraines. She is unable to tolerate preventative treatment medications because of her organic brain syndrome. Her abortive treatment regimen only provides some relief, leaving her bedridden at least two days per month. In addition, a review of the submitted documentation reveals that the patient has reduced her usage of butalbital, which was previously prescribed almost monthly. In light of these results, additional Botox injections are medically appropriate and indicated for treatment of the patients migraine headaches.  Based upon the information set forth above, I have determined that the requested therapy is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.