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

A 56-year-old female enrollee has requested estrogen pellet implantation for treatment of her menopausal symptoms. Findings:  Three physician reviewers found that in this case, the patient is receiving non-FDA approved pellet therapy (as well as injectable estrogen therapy), and there is no indication as to what other FDA approved estrogen products and routes have been tried.  FDA approved routes and products can be oral, transdermal patches, gels and sprays, as well as vaginal administration (a vaginal ring that releases estrogen sufficient to treat hot flashes).   Blood measurements of her estradiol levels show she is exposed to very high levels of estrogen on a chronic basis, and there may be safety issues involved with using such amounts in a menopausal woman (including risks of stroke, thrombosis, and breast cancer).  In this clinical scenario, estrogen pellet implantation is not likely to be the most efficacious treatment alternative.
Appeal type: Experimental/Investigational
Decision: Upheld

A 54-year-old female enrollee has requested single-photon emission computed tomography (SPECT) scan for evaluation of her medical condition. Findings:  Two physician reviewers found that in this case, the services at issue were not likely to have been more efficacious than other modalities for evaluating this patient.  A SPECT scan is not needed for the diagnosis of Parkinsons disease.  Although there is some literature supporting the use of SPECT scans in differentiating between Parkinsons disease and essential tremor, this patients medical records do not suggest this clinical scenario.  The benefits of the SPECT scan for this patient over standard management has not been demonstrated.  Thus, the SPECT scan performed on the date indicated was not likely to have been more effective than other methods of evaluation.
Appeal type: Medical Necessity
Decision: Upheld

A 55-year-old female enrollee has requested surgical correction of left eye swelling and pain and sunken right eye for treatment of the enrollee status post upper and lower blepharoplasty.  Findings:  The physician reviewer found that the photographs and patient records do not reveal a distortion severe enough to be considered an abnormal structure. The photographs show no ptosis, lid lag or ectropion. There is mild left malar swelling/prominence relative to the right and a mild to moderate visible tear trough on the left. This is more severe on the right extending laterally into a visible palpebromalar groove. There is a slight indented area around the left lateral canthus. There is marked brow ptosis causing a psuedodermatochalasis of the upper eyelids. This does not appear to be severe enough to cause visual field obstruction and the records contain no documentation of this complaint. The upper medial fat pads are visible, more so on the right. All told, the physical examinations and photos do not document any abnormal structure of the body. With regard to the medical necessity of the proposed surgery, there is no evidence that the patient is experiencing visual field obstruction post cosmetic surgery. Further, while she states that she has pain and numbness, the medical record documentation is primarily related to the patients complaints concerning her appearance rather than reports of pain and/or discomfort. Nor is there evidence that further surgical intervention will help improve any pain or discomfort the patient is experiencing. As such, the medical necessity of the requested surgery has not been established.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested diastasis recti repair for treatment of her abdominal pain and lower back pain.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure. Based on an evaluation of the submitted medical records this patient is documented to have a ventral hernia. The patient reports abdominal and back pain and the ventral hernia is documented to be contributing to her pain. A ventral hernia can lead to intra-abdominal problems including obstruction and incarceration of the bowel and can also be associated with pain. Moreover, these symptoms are not consistent with diastasis recti, which is a stretching of the abdominal wall and not a true hernia.  Coriddi and colleagues evaluated the functional status of diastasis recti following abdominoplasty and concluded that Rectus plication did not significantly improve functional outcomes. Thus, the proposed diastasis recti repair is not likely to resolve the patients functional issues and therefore is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the AmniSure rupture of membranes (ROM) test. Findings:  The physician reviewers found that the diagnosis of ROM is made based on patient history and clinical exam including a speculum evaluation of the vagina and cervix. Typically, the patient history with a description of leakage of fluid, a sterile speculum exam to evaluate pooling and the pH of any secretions, and a microscopic examination for cervical ferning complete the exam. From a review of the chart, it appears that the patients cervix was noted to be long and closed. Both evaluation of pooling of fluid and amniotic ferning testing were negative. She was determined to have a bacterial vaginosis infection and was appropriately treated. At the initial time of the pelvic exam, a vaginal swab for AmniSure testing was also done. The patient was also noted to not be contracting, had a reassuring fetal status, and had no further leakage of fluid. Thus, a complete speculum exam would have been adequate to rule out ROM in this clinical presentation, especially given that no pooling or ferning was appreciated. If the work-up including the clinical history or elements of the traditional pelvic/speculum exam were ambiguous or conflicting, then further evaluation with testing my AmniSure may have been warranted. In this clinical setting, the AmniSure ROM test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Results: 2 of 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 reviewers number one and two are board certified in obstetrics and gynecology and are actively practicing. Physician reviewer number three is board certified in obstetrics and gynecology with sub-specialty certification in maternal and fetal medicine 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tertiary level vascular surgery second opinion consultation. The records provided for review document that this patient has unique characteristics that warrant evaluation and treatment at a higher level of care. Specifically, the patients body mass index (BMI) supports a finding of morbid obesity and the duplex results suggest the potential development of recurrent deep vein thrombosis (DVT) that has not been addressed. There is concern for the possibility of an undiagnosed DVT in the left lower extremity. In this clinical setting, evaluation and treatment at the tertiary level of care is appropriate. Given these findings, the requested tertiary level vascular surgery second opinion consultation is medically necessary for 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 general surgery with subspecialty certification in vascular surgery 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 patient has requested reimbursement for inpatient psychiatric hospitalization level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.This gives the patient a composite score which is consistent with medically monitored residence-based services. However, given the patients score for risk of harm, he qualifies for medically managed residence-based services, such as inpatient level of care. Accordingly, the inpatient psychiatric hospitalization level of care was medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for bilateral knee braces for treatment of the enrollees knee injury. Findings: The physician reviewer found that the evidence-based medical guidelines state that there are limited high quality studies that support or refute the benefits of knee braces for patellar instability, ACL tear, or medial collateral ligament instability. However, studies have found that in some patients a knee brace can increase confidence, which may indirectly help with the healing process. Pre-fabricated knee braces may be appropriate for patients with knee instability or ligament insufficiency/deficiency. Custom braces are supported when there is abnormal limb contour, such as disproportionate thigh and calf, precluding the use of a pre-fabricated brace. In all cases, braces need to be used in conjunction with a rehabilitation program and are medically appropriate if the patient is going to be stressing the knee under load. Bedi and colleagues concluded that there was a lack of high-quality evidence regarding immobilization, weight-bearing, bracing, or rehabilitation protocols for patients with posterior cruciate ligament injuries treated either non-surgically or surgically. Additional long-term clinical studies with homogeneous patient populations are needed to identify the ideal management of these injuries. In another study by Jansson and colleagues, they found that little evidence exists from the eight relevant articles to support the biomechanical efficacy of non-operative and postoperative PCL bracing protocols. This patient presented possible imaging evidence of a posterior cruciate ligament longitudinal tear with no disruption and no complaints of instability. The orthopedic appeal letter stated that the patient sustained a PCL injury to his left knee rendering the knee unstable in flexion. There is a current report of instability in flexion, with some medial and patellofemoral pain. However, there was a lack of evidence to show abnormal limb contour to support the medical necessity for the braces at issue. This patient had a diagnosis of left knee injury with no documentation of an ACL or PCL ligament tear or knee instability to support the medical necessity of wearing a brace. For the reasons stated above, the two knee braces were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the devices 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 orthopedic surgery 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 skilled nursing facility (SNF) inpatient stay for treatment of the enrollees transverse myelitis secondary to lupus or antiphospholipid syndrome, and recent perforation of the rectum status post partial colectomy. The physician reviewer found that the patients request for SNF inpatient stay because of paralysis from transverse myelitis secondary to lupus was and is medically necessary. Her current functional status is significantly lower than her baseline. Studies have shown that recovery from transverse myelitis is seen during months three to six after symptom onset and may continue for up to two years and recovery may be rapid during months three to six after symptom onset. As such, the patient will continue to benefit from more intensive rehabilitative therapy in a SNF because she is within the window of time when recovery from transverse myelitis is expected. Many patients with transverse myelitis will require rehabilitative care to prevent secondary complications of immobility and improve their functional status. Studies suggest daily land and/or water based therapy for 8 to 12 weeks, and weight bearing exercises for 45 to 90 minutes daily in both early and late stages of rehabilitation. The patients requested SNF inpatient stay will allow her to continue suggested daily therapy and exercises for functional recovery, this would be difficult to achieve with home health therapy. Moreover, functional recovery in transverse myelitis patients with lupus may occur later in the disease process. Thus, the SNF services are supported as medically necessary. 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 internal medicine with sub-specialty certification in geriatric 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: Upheld

A 48-year-old female enrollee has requested integrative medicine services for treatment of her metastatic breast cancer. Findings:  The physician reviewer found that although stage IV breast cancer is incurable, there is a lot of variability in patient survival times due to heterogeneous tumor behavior and treatment responses.  The steroidal and nonsteroidal aromatase inhibitors are important drugs that have benefit for stage IV patients in randomized clinical trials, although tumors may progress.  In the setting of tumor progression, the mammalian target of rapamycin (mTOR) pathway has been thought to account for resistance to endocrine therapy.  In the trial by Baselga and colleagues, patients with early and advanced hormone receptor positive disease were randomized to exemestane and everolimus, an mTOR kinase inhibitor, versus exemestane on its own.  Progression-free survival was the endpoint, and the analysis showed that the combination treatment arm had a median survival of 10.6 months compared with 4.1 months for exemestane alone.  This was highly statistically significant, showing improved progression-free survival in patients receiving both drugs.  The patient is being treated with the standard options, and she can receive the current regimen in-network.  In this patients case, the requested integrative medicine services are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing (genetic testing). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent breast cancer.Findings:  Three physician reviewers found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise but is not yet ready for routine clinical use.  Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible in both a timely and cost-achievable manner, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. As such, Guardant360 testing (genetic testing) was not likely to have been superior over the available standard techniques for the evaluation of this patients medical condition.Final Result: All three reviewers determined 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:  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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hizentra 7 grams, once weekly. The requested Hizentra 7 grams, once weekly, is not medically necessary for treatment of this patients primary immunodeficiency. There is a lack of evidence that Hizentra is more effective than the Health Plans formulary alternative, HyQvia. HyQvia is a once monthly subcutaneous immunoglobulin therapy with recombinant human hyaluronidase, which allows a larger amount of immunoglobulins to reach the subcutaneous tissue and be absorbed into the bloodstream to help fight infection. This patients records do not include documentation of an adequate trial of or a contraindication to HyQvia. Due to the lack of a prior trial or presence of contraindications with the preferred agent, the requested Hizentra 7 grams, once weekly is not medically necessary for treatment of this patients primary immunodeficiency. 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: The reviewer is board certified in internal medicine with sub-specialty certification in allergy and immunology 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 54-year-old female enrollee has requested a computed tomography (CT) scan of the heart for evaluation of her shortness of breath and dizziness with a family history of early coronary artery disease.  Findings:  Three physician reviewers found that this patient presents with shortness of breath but no chest pain. She has two risk factors and no previous cardiac disorder. Currently, the utility of coronary calcium scoring with CT scan of the heart is not supported in the peer-reviewed medical literature. The role of coronary calcium score and its benefit on future outcomes is not well defined. All told, the CT scan of the heart was not likely to provide this patient with an improved health outcome beyond that expected with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested anesthesia services administered during an endoscopy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that upon review of the submitted records, this patient presents without comorbidities that would require the services of an anesthesiologist during an endoscopy procedure. The guidelines set by the American Society for Gastrointestinal Endoscopy (ASGE) guidelines and the American Society of Anesthesiologists (ASA) set forth the following: The assistance of an anesthesia specialist should be considered for ASA physical status III, IV, and V patients. Other possible indications for involvement of an anesthesia professional during sedation include emergency endoscopic procedures, complex endoscopic procedures, and patients with a history of (1) adverse reaction to sedation, (2) inadequate response to moderate sedation, (3) anticipated intolerance of standard sedatives (e.g. alcohol or substance abuse), and (4) those at increased risk for sedation-related complications, such as patients with severe comorbidities or with anatomic variants predictive of increased risk for airway obstruction or difficult intubation (e.g. morbid obesity or sleep apnea). In this case, the patient did not present with a significant history that would require the services of an anesthesiologist for the procedure performed. As such, anesthesia services administered during an endoscopy was not medically necessary in this clinical setting.  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 anesthesiology with sub-specialty certification in pain 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.