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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 Comprehensive Liquid Biopsy.Findings:  Two of the three physician reviewers found molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Thus, Guardant360 Comprehensive Liquid Biopsy was likely to have been superior over other modalities for evaluating this patient. 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 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing (CPT 81162 and 81307). Findings:  The physician reviewer found that patients with BRCA1 mutations can be at increased risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. In addition, BRCA2 mutations can increase a patients risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests are negative, there is still a possibility of hereditary predisposition from another gene defect. This patient has a history of one a maternal grandmother with breast cancer, but there is no other history that indicates the presence of a cancer syndrome. In this clinical setting, the recommended course of action includes genetic counseling followed by ordering the appropriate testing. Based on the available documentation, the genetic testing (CPT 81162 and 81307) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the genetic testing (CPT 81162 and 81307) 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 services at issue were 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: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology 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: A 56-year-old male enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. 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), all patients with chronic HCV should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive, genotype 1 patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Zepatier 50-100 mg tablets for 12 weeks is medically necessary for the treatment of this patient. 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 two-year-old female enrollee has requested for speech therapy for treatment of the enrollees delays in expressive language skills. Findings:  The physician reviewer found that Law and colleagues, approximately 6% of children have speech and language difficulties.  The authors noted that children whose difficulties persist into primary school may have long-term problems concerning literacy, socialization, behavior, and school attainment.   These reviewers concluded that there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  In a recent review of therapeutic intervention for children with speech and language delay, McLaughlin noted that there are good data available to support the effectiveness of speech-language therapy, particularly for children with primary expressive language disorder. All told, the requested speech therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old female enrollee has requested physical therapy sessions for the treatment of the enrollees fibromyalgia (back pain). Findings:  The physician reviewer found that This patient was prescribed additional PT sessions for her additional complaint of back pain, but by the end of 15 sessions when no significant progress was noted and there was enough time to establish a home exercise program, her skilled PT could have been safely discontinued. The PT delivered on the dates in question were maintenance in nature and should not be covered as it was not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a negative impact on quality of life, especially in patients with moderate or severe disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. This patient requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla 30 mg tablets are medically necessary for the 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections in the right knee.Current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. As such, the Academy does not currently support viscosupplementation as standard treatment for osteoarthritis of the knees. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, the patient has a history of relief from prior viscosupplementation. Furthermore, the patients options are limited. The patient has tried and failed other conservative treatments including corticosteroid injections, an unloading brace, and physical therapy, with the alternative being a total knee arthroplasty. Under these circumstances, the requested Orthovisc injections in the right knee are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old male enrollee requested anastrozole (Arimidex) 1 mg for medical treatment of the enrollees hypogonadism.  Findings:  The physician reviewer found that according to the American Association of Clinical Endocrinologists (AACE) guidelines, treatment of male patients with hypogonadism involves treatment with testosterone therapy. Currently, there are no randomized prospective studies demonstrating the safety or efficacy of Arimidex when used in combination with testosterone therapy in the treatment of male hypogonadism. Consistent with these findings, the requested use of Arimidex is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for psychiatric inpatient 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. Applying the LOCUS framework, this patient did not meet the criteria for psychiatric inpatient care. For dimension 1, the patient was at moderate risk of harm (score 3) given his profound decline in function and his inability contract for his safety. The records indicate that the patient could not agree to keep himself safe outside of the inpatient hospital setting. For dimension 2, the patient demonstrated serious functional impairment (score 4) since he was not able to work, bathe or change his clothes due to his severe depression. For dimension 3, the patient has minor comorbidities (score 2) with a history of obesity and obstructive sleep apnea. For dimension 4, the patients recovery environment was moderately stressful (score 3) given his marital discord with his wife. In addition, the patients recovery environment provided limited support (score 3) due to the patients relationship issues with his wife. For dimension 5, the patient has exhibited poor response to treatment and recovery management (score 4). The records document that the patient has failed treatment at the outpatient, intensive outpatient program (IOP), and partial hospitalization program (PHP) levels of care. Moreover, the patient has not experienced substantial improvement with medications including Zoloft, Paxil, Lexapro, and amitriptyline. For dimension 6, the patient was optimally engaged in his recovery (score 2). The provider reported that the patient was adherent and cooperative with his treatment. These findings give the patient a composite score of 21, which is consistent with medically monitored community-based services. Per LOCUS, the patients score of 4 on functional status meets the requirement for Level 5 medically monitored residence based services, but he does not meet the criteria for Level 6 medically managed residence based services. Therefore, the psychiatric inpatient care was not medically necessary for treatment of this patient.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for antigen therapy services and immunotherapy injections. Findings:  The physician reviewer found that there is sufficient support for the medical necessity for the requested services in this clinical setting. Allergy immunotherapy, administered in a medical facility, is medically necessary for the treatment of the following IgE mediated allergies: allergic (extrinsic) asthma, dust mite atopic dermatitis, hymenoptera (bees, hornets, wasps, fire ants) sensitive individuals, mold induced allergic rhinitis, perennial rhinitis, and seasonal allergic rhinitis or conjunctivitis. After reviewing the clinical information, the patients diagnoses include seasonal allergic rhinitis and perennial allergic rhinitis. The progress notes indicate positive skin test results for pollens, dust mites, and mold.  Moreover, the progress notes have indicated that the patient has tried intranasal steroids, oral antihistamines of both first and second generations. Behavioral modifications have not resolved his symptoms. Therefore, the requested antigen therapy services and immunotherapy injections are medically necessary for treatment of this 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 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: Medical Necessity
Decision: Upheld

The parent of a 16-year-old male enrollee has requested resumption of intensive outpatient program treatment for the enrollees cannabis abuse, major depressive disorder, recurrent episode, and history of attention deficit disorder. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate that treatment at the intensive outpatient program level of care is medically necessary.  The patient completed intensive outpatient programming, and he had an aftercare plan in place.  There was no mention in the medical record of clinical deterioration or failure to meet treatment goals that would warrant an extension of intensive outpatient program services.  Additionally, the best evidence for treatment of cannabis dependence is motivational interviewing or cognitive behavioral therapy in the outpatient setting.  This patient does not need treatment at this level of care for his diagnosis of major depressive disorder, which incidentally was diagnosed during his period of drug use.  Thus, a substance-induced mood disorder may be an accurate reflection of his clinical status.  In sum, resumption of intensive outpatient program treatment is not medically necessary in this clinical setting.  The level of care that is medically necessary is outpatient treatment along with community programming.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Synvisc (hyaluronan) injections for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that colleagues concluded that there is a general lack of reliable evidence that any specific brand is superior to others. However, some clinically important reductions in pain have been noted, after closer review of systematic reviews and meta-analyses, using higher molecular weight and cross-linked formulations. Synvisc and Synvisc One are crosslinked with molecular weight 5-6 M (million Daltons). Euflexxa (2.4-3.6 M) and Orthovisc (1-2.9M) are not cross-linked. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. This patient presented with severe bilateral knee pain, left greater than right. Pain interfered with sleep and activities of daily living. The patient had failed to improve with ibuprofen. The patient had prior viscosupplementation years prior which helped for over years. X-rays showed severe degenerative arthritis of both knees, bone on bone in the left knee. Clinical examination documented limited range of motion with crepitus. She received Synvisc One injections into both knees on with excellent relief reported on the right side and no relief on the left side. Records documented that a subsequent corticosteroid injection was performed to the left knee. There was no documentation of additional Synvisc One injections in the submitted medical records. Criteria were met for the use of viscosupplementation for this patients medical condition. However, current evidence based medical guidelines and peer reviewed literature state that there is a general lack of reliable evidence that any specific brand is superior to others. There is no compelling rationale presented to support the medical necessity of Synvisc One over the formulary viscosupplementation agent. Therefore, Synvisc (hyaluronan) injections were not medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld

A 46-year-old male enrollee has requested authorization and coverage for computed tomography angiogram (CTA) of the heart. The Health Plan has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees hypercholesterolemia.Findings:  Three physician reviewers found that based on the records provided, the patient has some coronary risk and marked hyperlipidemia. In this circumstance of coronary risk and hyperlipidemia in a patient without chest symptoms, a screening coronary CT angiography is not medically indicated and not considered standard accepted practice. The national guidelines for evaluation and management of high cholesterol currently do not recommend coronary CT angiography in this clinical situation. In addition, the current expert consensus appropriateness guidelines that are endorsed by several national organizations also do not recommend coronary CT angiography for this purpose (Mark, et al). Moreover, results of coronary CT angiography in this particular patient would not likely change treatment since he is asymptomatic and has already proved to be intolerant of all statin therapy. Therefore, the requested coronary CT angiography is not expected to improve this patients health outcome and was appropriately denied by the Health Plan.