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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay. Findings:  The physician reviewer found that the patients American Joint Committee on Cancer (AJCC) stage alone, he had five-year and ten-year melanoma survival rates of 99 and 98% respectively. The gene expression profiling (GEP) test was subsequently performed and yielded a Class 1b score. Based on the GEP score alone, the patients five-year melanoma specific survival would be as high as 97%, signifying a relatively equivalent 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. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of cutaneous melanoma do not currently endorse the use of this test, and it is not incorporated into the most widely used treatment and management protocols. Therefore, the DecisionDx-Melanoma gene assay was not likely to have been more beneficial than any other available standard therapy for the patients medical condition.Findings:  Three of the three physician reviewers found the DecisionDx-Melanoma gene assay at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in dermatology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 19-year-old male enrollee has requested an Abbott FreeStyle Navigator continuous blood glucose monitor for the treatment of his diabetes mellitus. Findings:  The physician reviewer found that this patient has uncontrolled diabetes mellitus type 1 due to his Aspergers syndrome which inhibits his ability to remind himself to check his blood glucose and therefore administer insulin. A CGMS has been recommended to assist the patient in achieving better control. Given the patients elevated HbA1c, complications are likely to occur without the use of a CGMS. The patient is an appropriate candidate for a CGMS and is likely to benefit from its use.
Appeal type: Experimental/Investigational
Decision: Upheld

A 52-year-old male enrollee has requested for Cyberknife stereotactic body radiotherapy (SBRT) for treatment of her adenocarcinoma of the prostate.   Findings:  Three physician reviewers found that he would be deemed a low recurrence risk based on current National Comprehensive Cancer Network (NCCN) practice guidelines.  In addition, with life expectancy greater than 20 years, options regarding definitive treatment would include observation, radical prostatectomy, 3D conformal irradiation, or interstitial implant. Furthermore, within the NCCN guidelines under Principles of Radiation Therapy, it states that 3D conformal or IMRT techniques should be employed.  Doses of 70 to 79 Gy in 35 to 41 fractions to the prostate appear to be appropriate for patients with low risk cancer.  This dose fractionation is not consistent with stereotactic body radiosurgery which typically employs large doses over a short period of time. The NCCN guidelines do not state that Cyberknife treatment is considered optimal or even an option if stereotactic body radiosurgery is utilized.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the FoundationOne gene testing for evaluation of the enrollees sarcomatoid carcinoma. Findings:  The physician reviewer found that FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne test was 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 testing at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that A [partial hospitalization program] PHP is appropriate when meal supervision is needed without requirement for 24-hour supervision. PHP admission generally requires that patients be at or above minimally acceptable weight (e.g., greater or equal to 80% of ideal body weight) and maintain other evidence of medical stability. The patient had improved and weighed 113.6 pounds and was at 86% of her ideal body weight. The patient did not have any suicidal ideation. She was not administered any as needed medications. She reported on many occasions that she desired to be treated in a less restricted environment. She was medically stable and did not have orthostatic hypotension. The documentation reported that she continued to be anxious and depressed. Although the patient continued to require treatment, she did not require 24-hour supervision, and she could have been treated in a less restrictive environment. For the reasons provided, the residential treatment center services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, the records document that the patient has experienced alcohol induced seizures and daily blackouts, which place the patient at risk for withdrawal. The patient meets dimension 2, due to his history of alcohol poisoning and fractures from falls while intoxicated. For dimension 3, the patient has post-traumatic stress disorder (PTSD) with anxiety, depression, and irritability. The patient meets dimension 4, as he is generally motivated but unready to dig deeper and obtain insight. The patient does not have the recovery skills necessary to maintain sobriety. For dimension 5, the provider noted that the patient remains at high risk of relapse due to his poor insight into the disease of addiction and no coping skills to address his anxiety other than substance use. The patient also meets dimension 6, as the providers noted that the patient requires more of the structure and support provided at the RTC level of care. In the community, the patient has poor support and strained relationships with family. The patient requires a safe and stable living environment in order to develop his recovery skills. Based on the documentation reviewed, the patient qualifies for ASAM Level III treatment, which is similar to the services provided at the current RTC. Given the severity of the patients illness, the RTC services provided were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

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 joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies to all patients, regardless of fibrosis stage.  Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as 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: Upheld

A fifty-six year-old obese female is requesting authorization for Lap-Band surgery.  Reviewers Findings:The reviewing physician found that because of the patients current BMI and the absence of significant comorbid conditions, the patient does not meet the guidelines set by the National Institutes of Health for weight loss surgery.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for diagnostic laparoscopy. The records provided for review document that this patient has computed tomography (CT) evidence of involvement of the mesenteric root, which is unresectable. Per National Comprehensive Cancer Network (NCCN) guidelines, diffuse infiltration of the root of the mesentery or para-aortic lymph node highly suspicious on imaging is a contraindication to resection. The patient currently has ample radiographic evidence for unresectable and metastatic disease. In this clinical setting, no further testing is indicated. While there is no definitive histologic proof of metastatic disease, further biopsies would only be invasive, adding to the risk of complications and any delays in care required to promote healing and recovery from surgery. All told, the requested diagnostic laparoscopy is not medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in general 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: Upheld

A male enrollee requested Vyvanse for medical treatment of his behavioral health condition.  Findings:  The physician reviewer found that the medical record does not substantiate the medical necessity of lisdexamfetamine. The patient was prescribed opiate and benzodiazepine medications that, in addition to being susceptible to tolerance and dependence, commonly result in cognitive impairment. Furthermore, the patient was not diagnosed with ADHD by the treating provider. Based on the documentation provided including the diagnostic uncertainty of ADHD, the prescription of lisdexamfetamine for this patient is not medically necessary. As such, the requested medication is not medically necessary for treatment of the patients behavioral health condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Serostim 4 mg vial. The records provided for review document that this patient has a history of panhypopituitarism following resection of a pituitary adenoma many years ago. The patient has been treated with multiple therapeutic agents including hydrocortisone, levothyroxine, and growth hormone replacement therapy. The provider charted that the patient is experiencing worsening quality of life due to fatigue related to her panhypopituitarism since she stopped taking growth hormone therapy. Her provider has recommended treatment with Serostim. The syndrome of growth hormone deficiency in adulthood is characterized by alterations in body composition and decreased capacity for exercise as well as unfavorable changes in cardiovascular function, and lipid and carbohydrate metabolism (Diez, et al.). Diagnosis of growth hormone deficiency is based on the combination of pituitary disease, hypopituitarism and a decrease in the concentration of insulin like growth factor 1 (IGF-1) or in diminished growth hormone responses to different stimuli. However, in patients with a clear pituitary lesion and a markedly subnormal IGF-1, a stimulation test may not be needed (Alexandraki, et al.). Multiple studies have demonstrated that long-term daily growth hormone replacement therapy can ameliorate or reverse many of the effects of growth hormone deficiency, including beneficial effects on muscle and fat mass, lipid profile, diastolic blood pressure, and bone mass (van Bunderen and Olsson). For these reasons, the requested Serostim 4 mg vial is medically necessary for treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. Moreover, treatment delays may decrease the benefit of SVR. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. In addition, per AASLD/IDSA guidelines, daily daclatasvir and sofosbuvir for 12 weeks is recommended for treatment-naive patients with HCV genotype 3 infection. The ALLY-3 study concluded that a 12-week regimen of daclatasvir plus sofosbuvir achieved SVR at 12 weeks in 96% of patients with genotype 3 infection without cirrhosis and was well tolerated. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Sovaldi and Daklinza for 12 weeks is medically necessary in this case. Final Result: The reviewer determined that the requested medications 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 33-year-old male enrollee has requested for real-time cardiac monitoring for evaluation of his palpitations. Findings:  Three physician reviewers found that the documentation does not include a report of a standard Holter monitoring study.  No record was submitted of any attempted pharmacological treatment.  In this patients case, a standard 48-72 hour Holter monitor would have been appropriate to detect the arrhythmia. In this clinical situation, remote monitoring was premature.  More standard diagnostic approaches should have been employed prior to remote monitoring. In this patients case, the superior efficacy of real-time cardiac monitoring over more standard approaches has not been established.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lymphovenous bypass surgery Findings:  The physician reviewer found that medical literature supports the use of lymphovenous bypass surgery in reducing the severity of the symptoms of lymphedema. Schaverien and Coroneos note that lymphedema may result in long-term disability and functional impairment that may be ameliorated by lymphovenous bypass procedures. Chang and colleagues report that lymphovenous bypass can be effective in reducing lymphedema severity. In this case, in a letter dated 12/8/20, the provider reported that the patient had a progressive history of worsening right lower extremity primary lymphedema and was compliant with conservative therapy, including compression, pump, manual lymphatic drainage, and elevation. The patient was status post lymphovenous bypass surgery in December 2019 with great improvement. The provider recommended a repeat lymphovenous bypass procedure for continued control of symptoms, reporting that left untreated, lymphedema could lead to cellulitis, sepsis, disability, and even death, along with significant disability. In this clinical setting, given the failure of conservative measures in controlling the patients symptoms, and the patients improvement following his first surgery, the providers recommendation for a repeat lymphovenous bypass surgery is supported. Therefore, the requested lymphovenous bypass surgery  is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the lymphovenous bypass surgery is 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 service is 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: Physician reviewers 1 is board certified in surgery and in plastic surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in plastic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection (HCPCS code J7325) in each knee. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as standard treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, the patient has a long history of osteoarthritis of both hips and both knees. The patient benefitted from viscosupplementation with Synvisc One. The patient reported having difficulty walking up and down the stairs to his residence. Given the patients prior positive response, the requested Synvisc One injection (HCPCS code J7325) in each knee is medically necessary for treatment of 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 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.