Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: This patient is a male with a diagnosis of chronic plaque psoriasis. This patient has failed first-line therapies with high potency topical steroids. The provider reported treatment with apremilast (Otezla) had shown good therapeutic effect in the past for this patient. Other injectable biologics and cytotoxic drugs have been avoided due to their immunosuppressive properties and potential side effects.At issue in this case is whether the requested Otezla is medically necessary for treatment of the patients medical condition. Psoriasis is a chronic inflammatory skin disease that typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently avoided because of renal, hepatic, and pulmonary toxicity and limited efficacy. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events. Otezla is U.S. Food and Drug Administration approved for the treatment of plaque psoriasis. In a study by Bissonnette and colleagues, Otezla was studied in more than 4,000 patients, and the safety profile was consistent across indications. In this case, the patient has chronic plaque psoriasis that requires systemic treatment. He has failed treatment with high potency topical steroids, methotrexate and Humira. The patient has already been successfully treated with Otezla. Therefore, Otezla is medically necessary for treatment of the patients medical condition.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 dermatology 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested a virtual colonoscopy (CT colonography) for evaluation of her history of colon polyps. Findings:  The physician reviewer found that virtual colonoscopies are not medically indicated for patients with a known history of polyps. Additionally, the requested diagnostic procedure is not indicated for patients with severe rectal bleeding. The U.S. Preventive Services Task Force has concluded that there is insufficient evidence supporting the use of virtual colonoscopies. Colonoscopies are not generally performed with the use of general anesthesia. Rather, a very short-acting medication (propofol) or conscious sedation is used. There is a lack of medical evidence supporting the requested virtual colonoscopy for the evaluation of this patient. All told, the requested virtual colonoscopy (CT colonography) is not medically indicated for this patient.
Appeal type: Medical Necessity
Decision: Overturned

A 40-year-old female has requested coverage for past and future chiropractic treatment services for treatment of her intermittent neck and back pain.  Findings:  The physician reviewer found that current treatment guidelines state that the treating provider is expected to keep and maintain adequate case records clearly showing the patient care and clinical analysis from visit to visit. The following information is required within each subsequent visit: review of chief complaint; changes in the patients condition since the last visit; assessment of the patient since last visit; percentage of improvement, posture and gait analysis; pain scale; palliative and provocative assessment; range of motion; motor, sensory, and deep tendon reflexes (when warranted); systems review (especially if positive findings were documented with the last visit), including orthopedic and neurological evaluations of the area of the spine involving the diagnosis; evaluation of treatment effectiveness; and the treatment provided at time of visit. The records fail to support the patients care as medically necessary beyond a specific date at issue. Due to the lack of documentation provided, medical necessity has not been demonstrated for the treatment period beyond the date at issue. Thus, the initial examination and treatment provided was medically necessary and appropriate, however, the treatment provided subsequently and onward is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested a heart procedure to remove and replace leads to the pacemaker system for treatment of her fractured atrial peacemaker lead wire, atrioventricular (AV) block and pacemaker battery depletion.  Findings:  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested procedure. Based on the records provided for review, the patient has a 10-year-old device that has battery depletion, a malfunctioning atrial lead in spite of sensing adjustment, and a ventricular lead position that causes intermittent chest wall muscle stimulation affecting her quality of life. In this circumstance, generator and lead replacement is reasonable, appropriate and considered standard accepted therapy in the medical community. According to the medical literature cited above, current pacemaker guidelines that are endorsed by several national organizations consider pacemaker generator and lead replacement appropriate in this clinical setting. Therefore, a heart procedure to remove and replace leads to the pacemaker system is medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 66-year-old male enrollee has requested cryoablation of a kidney tumor for the treatment of his kidney tumor. Findings:  Two physician reviewers found that this patient has an enhancing small cystic left renal mass. This is suspicious for renal cell carcinoma. The patient has requested coverage for cryoablation of the kidney tumor. The Health Plan has denied this request, and the patient is appealing this denial. Ablative therapies of small renal masses have been shown to be very successful in the intermediate follow-up. The treatment of these lesions is still controversial. Options include observation, partial nephrectomy, and ablation procedures. Although long-term data is only available for partial nephrectomy, intermediate follow-up for observation and cryoablation appears to be very good. The requested procedure is reasonable and appropriate for this patients case.
Appeal type: Experimental/Investigational
Decision: Upheld

A 42-year-old male enrollee has requested an ultrasound bone growth stimulator for treatment of his non-healing calcaneal fracture of the left heel. Findings: Two physician reviewers found that the criteria for a nonunion fracture includes a three-month-old non-healing fracture with documentation and confirmation via serial x-rays that the healing has ceased or has been delayed. There also needs to be a fracture gap of 1cm or less. These findings are not supported in the medical records provided. Furthermore, even in cases in which criteria for nonunion fracture are met, there is inadequate evidence to support the superiority of bone growth stimulators as compared to standard therapies. Although several randomized trials exist which support a variety of bone stimulation modalities, these are small studies and limited primarily to radiologic endpoints. There remains a need to conduct large and more definitive trials before the benefits of the device can be adequately established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing performed with Castle Biosciences Inc. Based on the patients American Joint Committee on Cancer (AJCC) stage alone, she had five-year and ten-year melanoma survival rates of 99% and 93%, respectively. The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1a score. Based on the GEP score alone, the patients five-year melanoma specific survival would be as high as 100%, signifying a better prognosis for the patient. At this time, there is a lack of evidence indicating that this information can be used in a clinically meaningful way to benefit the patient, namely, how much less follow-up or screening would be safe for the patient given her current AJCC stage combined with GEP score. The National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma do not endorse the use of GEP testing at this time and it is not incorporated into the widely used treatment and management protocols. Therefore, DecisionDx-Melanoma genetic testing performed with Castle Biosciences Inc. was not likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing performed with Castle Biosciences Inc. 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) skilled services by a registered nurse for management and evaluation of the plan of care (CPT code G0162), 1 unit at 15 minutes each, and (2) direct skilled nursing services of a registered nurse in the home health or hospice setting (CPT code G0299), 3 units at each 15 minutes. Green notes that patients with dementia have unique safety needs due to cognitive and behavioral changes associated with dementia. The author further notes that safety interventions for persons with dementia who remain in their home environment should be considered to mitigate the risks associated with falling, kitchen use and food safety, medication safety, and wandering and personal safety. Despite these measures, constant supervision and caregiver assistance for safety may still be needed. Maayan and colleagues note that caring for someone with dementia can be emotionally and physically demanding. In this case, the patient has profound cognitive deficits. The records do not reflect skilled therapy needs or that the patient is capable of being rehabilitated. She requires indefinite assistance with basic care and mobility. Given that these services are custodial in nature, the requested services are not medically indicated. Therefore, (1) skilled services by a registered nurse for management and evaluation of the plan of care (CPT code G0162), 1 unit at 15 minutes each, and (2) direct skilled nursing services of a registered nurse in the home health or hospice setting (CPT code G0299), 3 units at each 15 minutes are not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for inpatient psychiatric hospitalization services. The enrollee has paranoid schizophrenia. The Level of Care Utilization System (LOCUS), developed by the American Association of Community Psychiatrists, is a level of care assessment tool widely used by clinicians throughout the country to support accurate level of care recommendations. The six dimensions of LOCUS include risk of harm, functional status, comorbidity, and recovery environment, level of support, and treatment and recovery history. The enrollees composite LOCUS score correlates with Level 5, medically monitored residential treatment center; however, due to the enrollees functional status, the more appropriate level of care is Level 6, inpatient level of care.Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial .  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Epclusa for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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

The parent of a 10-year-old male enrollee has requested  applied behavior analysis (ABA) services, 26 hours per week of direct care (H2019), nine hours per month of supervision (H0032) and nine hours per month of parent training (H0032) for treatment of the enrollees autism spectrum disorder. Findings:  Three physician reviewers found that there is sufficient support for the requested services in this patients case.  Per the current medical evidence, early intensive behavioral interventions are effective in terms of improving language, cognitive skills and adaptive skills.  This patient has made considerable progress with behaviors including elopement, aggression and self-injury.  He has made slower progress with communication and adaptive skills.  The current medical literature supports the requested services in this patients case.  The study by Hayward and colleagues noted the benefits of ABA services for children with autism spectrum disorder. The authors noted a better response to more intensive intervention (at least 25 hours per week) compared to less intensive intervention.  Based upon the clinical documentation provided, the patient continues to require ABA services at an intensive level. Thus, ABA services, 26 hours per week of direct care (H2019), nine hours per month of supervision (H0032) and nine hours per month of parent training (H0032) are medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 53-year-old female enrollee requested authorization and coverage of botox Injections for the treatment migraine headaches.  The health plan denied the enrollees request indicating that the requested treatment is experimental.Three physician reviewers performed an experimental/investigational Independent Medical Review.  Each of the three physician reviewers concluded that botox Injections are not likely to be more beneficial for treatment of the enrollees migraine headaches than any available standard therapy.  Because all three physician reviewers concluded that the requested treatment is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the review organization upheld the health plans denial.
Appeal type: Medical Necessity
Decision: Upheld

A 42-year-old female enrollee has requested a continuous passive motion machine for the treatment of her knee, status-post right knee arthroscopy. Findings:  The physician reviewer found that although the use of the CPM machine after joint surgery has gained popularity among orthopedic surgeons, the literature has been slow to establish evidence-based studies that support the use of the CPM machine for any type of knee surgery. The Health Plans denial of the use of a CPM device is appropriate given the lack of medical literature showing superior outcomes 6 months post surgery, or in other words, the end result is the same with or without the use of the CPM machine after 6 months. The clinical value of post-operative CPM therapy remains unproven in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in this patients case.  The current medical evidence supports the short-term and long-term benefits of bronchial thermoplasty in this clinical setting.  This patient is on an aggressive regimen for control of her asthma and associated conditions, and she has achieved little in the way of adequate control.  Given that prior interventions have not controlled the patients symptoms, bronchial thermoplasty is the appropriate next step in management.  In sum, the requested bronchial thermoplasty is likely to be superior over other treatment options. Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment 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 pulmonary disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine.  Findings:  The physician reviewer found that There is a lack of scientific data to support the efficacy of topical ketamine for CPRS (Harden; Abdi, et al). Further, this patients records provided for review do not document treatment with sympathetic blocks, spinal cord stimulation, or other standard therapies which have support of efficacy in the peer-reviewed medical literature. Given these findings, the requested topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested topical ketamine with lidocaine, baclofen, gabapentin, and cyclobenzaprine is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with subspecialty certification in pain medicine 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

A female enrollee requested breast tomosynthesis for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that  In this patients case, the services at issue were not likely to be of greater benefit than other modalities.  The records do not demonstrate that the patient was likely to have received additional benefit from breast tomosynthesis.  Her mammogram study was negative, with no change from the prior study.  The patients breasts were not dense on mammogram.  Therefore, breast tomosynthesis was not likely to be more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old male who has been experiencing fasciculations in his arms and hand for approximately one year. He also has pain and numbness in his left-sided extremities.  Diagnostically, he had an EMG, NCV studies and an MRI. The differential diagnoses include polyradiculopathy, multifocal motor neuropathy or early ALS.  The patients provider has requested authorization for IVIG therapy.  The Health Plan denied the request based upon a determination that the therapy is not medically necessary.There is no definitive diagnosis for this patient at this time. He has some neuropathological features on the nerve conduction study, but a diagnosis of multifocal motor neuropathy is not yet sustainable. The patient may have elements of radiculopathy or symptoms of early ALS.  Given the lack of a more definitive diagnosis, a trial of IVIG is speculative and not medically justified. Therefore, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.