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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 7/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested hip surgery for treatment of her medical condition. Findings: Two reviewers found that review of the medical records indicate that she meets the criteria for surgical treatment given the diagnosis of femoroacetabular impingement syndrome with hip pain that interferes with activities of daily living and has failed conservative treatment. MRI confirmed the presence of femoroacetabular impingement syndrome with evidence of CAM impingement in the form of an osseous ridge at the edge of the femoral neck, as well as a labral tear. In addition to the preoperative clinic diagnosis, the diagnosis was confirmed on direct visualization during the operative procedure. At this patients age, she is not a candidate for alternative procedures such as total hip arthroplasty which will likely require revision with increased risk level of revision for both mechanical complications and increased risk of infection. Treatment of femoroacetabular impingement syndrome is now well established and the technical requirements are well within the experience of an orthopedic surgeon skilled in arthroscopic techniques. In summary, the hip surgery was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the surgery at issue was 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 physician reviewers are board certified in orthopedic surgery 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 parent of an 18-year-old male enrollee has requested adolescent substance residential treatment services for the treatment of the enrollees behavioral health problems. Findings:  The physician reviewer found that the submitted clinical evidence demonstrates that residential placement was not medically necessary. The records indicate there were no detoxification risks or co-occurring medical issues that required monitoring. In addition, according to the treating psychiatrist and the Intake Assessment, the patient did not have prior consistent treatment for substance abuse and had not demonstrated an inability to address his substance abuse issues in a less restrictive setting. Furthermore, the patient was without any suicidal or dangerous ideation on admission or at any time during this stay. He demonstrated no safety issues that required 24 hour monitoring or supervision.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for residential treatment center (RTC) services. 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. Applying the LOCUS guidelines, the patient met the criteria for RTC services. The patient was at serious risk of harm (score 4) due to a recent pattern of excessive substance use resulting in loss of self-control and harmful behaviors. The patient has been unable to abstain from substance use as demonstrated by his behaviors, and his friends decision to express their concerns to his parents. The patient exhibited serious functional impairment (score 4) given his inability to engage in school, work or other obligations. The patient has significant comorbidity (score 3) considering the interaction between his depression and anxiety with substance use disorders. The patients recovery environment was moderately stressful (score 3) due to family discord and easy access to substances. The patients recovery environment was supportive (score 2) given her parents active participation in the patients treatment. The patient has demonstrated poor response to treatment (score 4). The records document that the patient failed to progress and reported continued symptoms despite intensive and repeated exposure to treatment. The patient was incompletely engaged in treatment (score 3) due to his resistance to participate in treatment and his pessimism about recovery. This gives the patient a composite score of 23, which is consistent with medically monitored residential services. Furthermore, the patient qualified for level 5C moderate intensity long-term RTC, due to minimal past response to treatment and uncontrolled substance use, which had a destabilizing effect on the patients anxiety and depression. Per LOCUS, for level 5C programs, the length of stay will vary from two months to a year. In this case, the recommended length of stay in the RTC was 90 days, which was the length of patients participation in the program. Given these findings, the psychiatric RTC services were medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for durable medical equipment (DME) electrical treatment (Nalu neurostimulation system peripheral nerve stimulation. Findings:  The physician reviewer found that 4 randomized control trials, Deer and colleagues reported moderate to strong evidence supporting the use of peripheral nerve stimulation (PNS) to treat pain, including in the sural, superficial peroneal, and lateral femoral cutaneous nerves. In a review of the bioelectrical implications of simulation of the PNS for chronic pain conditions, Deer and colleagues noted that PNS utilization produced consistently high success rates in achieving pain relief in well selected patients when delivered by skilled clinicians. In this case, the records noted a diagnosis of left sural neuropathy. The patient had tried and failed exhaustive conservative therapies, including physical therapy, steroids, and viscosupplementation. She was being managed on Cymbalta and peripheral nerve blocks. Visit notes reported that the patient underwent a left sural nerve PNS Nalu trial without complications. In this clinical setting, current medical literature supports the use of PNS as superior to conservative therapy which has already been tried and failed. Therefore, DME electrical treatment (Nalu neurostimulation system peripheral nerve stimulation)  is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested DME electrical treatment (Nalu neurostimulation system peripheral nerve stimulation) 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 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. Physician reviewer 2 is board certified in physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Forteo for treatment of the enrollees medical condition. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates.  Newer treatment agents have become available over the past few years, including teriparatide (Forteo), which was initially approved for treatment of osteoporosis in 2002.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone.  Recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high-risk for fracture, defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy.  The current medical evidence supports the requested medication in this clinical setting.  All told, Forteo is medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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: Experimental/Investigational
Decision: Upheld

The enrollee requested reimbursement for the DecisionDX-Melanoma genetic testing. The enrollee has a malignant melanoma on his left leg. The DecisionDX-Melanoma class was 2 and sub-class was 2A. A Class 2A signature is associated with an increased risk of recurrence within 5 years, relative to class 1. The enrollees surgical oncologist states the result of the test enables him to provide risk- specific surveillance and management for his enrollee. The DecisionDX-Melanoma gene panel may be used in clinical practice, but it is not currently recommended by any standard treatment guidelines. The DecisionDX-Melanoma has not had sufficient testing prospectively, and in a randomized controlled study, to make it standard of care. There is no evidence that this test will benefit the enrollee beyond standard of care, which is monitoring, and lymph node biopsy and excision.Final Result: The reviewers determined that the requested services were not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: The reviewers are board certified in dermatology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 172 hours per month of direct applied behavioral analysis (ABA) therapy and 22.5 hours per month of supervision for treatment of her autism. Findings:  The physician reviewer found that the request for 172 hours per month of direct ABA therapy and 22.5 hours per month of supervision is medically necessary for treatment of the patients autism. Research has demonstrated increased progress towards learning objectives with increased intensity of treatment for children with autism. In this case, the patient demonstrates problematic behaviors which include aggression, tantrum, motor stereotypy, mouthing, visual stereotypy and inappropriate touching. The patients inability to master these skills puts her at an increased risk for injury, and also makes it difficult to be successful in more generalized environments. Based on the clinical documentation provided for review, the requested services are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: The patient has requested authorization and coverage for Privigen (J1459) 80 units every four weeks. Chronic inflammatory demyelinating polyneuropathy (CIDP) is an autoimmune condition that affects the nervous system. The condition can cause intermittent exacerbations due to the demyelination of nerves and nerve roots. The use of intravenous immunoglobulin (IVIG) is the mainstay of the treatment of CIDP and is considered the standard of care for management of the condition. The records provided for review document that this patients treatment has included duloxetine, steroids, and gabapentin without substantial improvement. Since other treatments have failed, IVIG with Privigen is appropriate. Accordingly, the requested Privigen (J1459) 80 units every four weeks 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. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

An enrollee has requested authorization and coverage for morphine sulfate ER 15 mg twice per day. Findings:  The physician reviewer found that the records indicate that this patient underwent a random urine toxicology. The results indicated multiple non-prescribed agents including amphetamines, cannabis, hydrocodone and codeine. The provider subsequently discontinued morphine secondary to the non-compliance. Further treatment with opioids is therefore not indicated given the substantial issue of non-compliance with treatment plan. Non-opioid treatments should be pursued.  Final Result: The reviewer determined that the 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 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.
Appeal type: Medical Necessity
Decision: Upheld

A 19-year-old male enrollee requested authorization and coverage for continued partial hospitalization program (PHP) services provided from a specific date and forward. The Health Plan denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that, based on review of the available records, this patient did not require the intensity of PHP treatment for his medical condition. The provider notes indicated that the treating team would like the patient to remain in treatment, but the patient was not comfortable with that. The provider also listed a treatment alternative which was to transfer the patient into a halfway house. The patient was not experiencing any psychotic episodes or intent to harm himself or others. He had been encouraged to go on passes and more passes have been requested. Thus, applying the American Psychiatric Association (APA) treatment guidelines, the records do not support the medical necessity for PHP treatment for this patient for the requested dates. The therapists weekly summary indicated that the patient continued to do fairly well and further supported the position that services at the PHP level of care were no longer medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Three physician reviewers found that in the medical literature, Skaane and colleagues reported that the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate when used with standard mammographic imaging. Given these findings, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the 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 diagnostic radiology 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

A 33-year-old male enrollee requested authorization and coverage of an elective circumcision.  The enrollee believes that his lack of circumcision has caused  his wife an infection, and he does not wish to have this recur .  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested surgery is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollee has requested reimbursement for Guardant360 testing. Molecular diagnostic studies are considered within the current standard of care for patients with non-small cell lung cancer (NSCLC). Numerous gene alterations have been identified that impact therapy selection. 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. The National Comprehensive Cancer Network (NCCN) guidelines strongly recommends broader molecular profiling, with the goal of identifying rare driver mutations for which effective therapies are available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. This patient was diagnosed with NSCLC. The provider noted that on the initial biopsy, the only molecular marker evaluated was epidermal growth factor receptor (EGFR), and there was insufficient tissue for additional testing. In this clinical setting, the use of Guardant360 analysis avoided a repeat biopsy and yielded the necessary data to guide this patients treatment. All told, the Guardant360 testing was 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 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in medical oncology 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.