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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Foundation One test provided for evaluation of the enrollees non-small cell lung cancer. Findings:  2/3 of the physician reviewers found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient is with a diagnosis of physiologic phimosis. On 6/29/17, the records noted the presence of smegma under the foreskin. The records noted no issues with urination. Consultation dated 1/28/19 reported the patient had no voiding problems and had no infections. The provider reported the distal foreskin was tight with phimosis. The provider is recommending a circumcision. On 3/12/19, the parents reported that they noticed blood and irritation on the penis. The parents did not report that the patient had issues with urinating. The provider recommended following up with urology and nystatin-triamcinolone cream. The patients parent has requested authorization and coverage for circumcision. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. At issue is whether circumcision is medically necessary for the treatment of this patient. Circumcision in the absence of pathologic phimosis that is unresponsive to gentle retraction or retraction assisted by betamethasone and or clobetasol topically, represents a cosmetic choice when unaccompanied by recurrent infection. Normal hygiene achieved by local care of the uncircumcised phallus with retraction at or about puberty is equivalent to circumcision in achieving health parameters. Medical benefits of circumcision do not warrant routine circumcision based upon current peer-reviewed literature. In this case, there is no documentation of recurrent infection. Therefore, the requested circumcision is not medically necessary for the treatment of the patients medical condition.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 urology with sub-specialty certification in pediatric urology 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 mother of an eight-year-old male enrollee has requested for a referral to a pediatric urologist for treatment of the enrollees phimosis. Findings:  The physician reviewer found that there is no evidence of penile abnormality other than phimosis with a redundant and periodically inflamed prepuce. The patients condition can be appropriately evaluated and treated by an adult urologist and does not require the services of a pediatric urologist.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old female with bronchiectasis who experiences numerous pseudomonas infections. The patients provider has recommended tobramycin inhalation solution (TOBI) to decrease the pseudomonas. The Health Plan indicates there is insufficient scientific evidence demonstrating TOBI is safe and effective for treatment of the patients condition. Therefore, the Health Plan has determined TOBI is not medically necessary for treatment of the patients medical condition.The patient who has bronchiectasis also apparently has numerous exacerbations. The inability of patients with bronchiectasis to effectively clear secretions results in frequent pulmonary infections. One of the more difficult organisms to treat is pseudomonas. In patients such as this patient, TOBI has been beneficial in decreasing exacerbations.  Alternative standard therapy has not been satisfactory in this case. The patient is likely to achieve better results with TOBI than with continued attempts at standard therapies. Based upon the information set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned. The patient should receive a six-month trial of TOBI with re-evaluation at the end of the six-month period.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services four times per week. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS framework, this patient meets the criteria for IOP services four times a week. The findings give the patient a composite score which is consistent with high intensity community based services, such as IOP. Furthermore, per CALOCUS, minimal oversight should be required for this level of services and reviews should not be required more than every two weeks of persons with acute conditions and every two months for those with more slowly evolving conditions. Given this patients presentation over the past two years, his condition can be considered chronic in nature and slowly evolving. For these reasons, the IOP services four times per week 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monurol. At this time, Monurol is an appropriate treatment for this patient with disabling recurrent urinary tract infections. The records report that the patient has experienced breakthrough infections while on nitrofurantoin post coital prophylaxis therapy. Furthermore, the patient has documented allergies to various antibiotics, which limits the available agents. The patients current regimen with Monurol is medically necessary for treatment of this 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 urology 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

A 40-year-old female enrollee has requested a STS continuous glucose monitoring system (CGMS) for treatment of her type I diabetes mellitus.   Findings:  Three physician reviewers found that Studies have demonstrated improved glycemic control with the CGMS. This technology is FDA approved and has been proven to alter the physiologic disease process, such as the frequency of hypoglycemia and the improvement in hemoglobin A1c values. There are few, if any, harmful effects. The CGMS is not considered investigational and this patient is an ideal candidate for the STS system. She has type I diabetes, had episodes of hypoglycemia and a hemoglobin A1c of 7.1% (goal = 6.5%) on insulin pump therapy. The patient had been checking blood sugars six to eight times daily, but this did not produce the same positive results as the CGMS. The patient is likely to benefit from long-term use of the STS system along with her insulin pump.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested reimbursement an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Two physician reviewers found that Oncotype DX assay has been found to be reliable in predicting the risk of cancer recurrence within ten years, if the only systemic treatment the woman receives is a hormonal therapy. It has only been validated in node-negative, estrogen receptor positive cancers. It is very difficult to make recommendations about adding adjuvant chemotherapy for this particular group of women. Not only does the Oncotype assay reliably predict the risk of recurrence without chemoterapy, it has also been found to predict the value of chemotherapy. Oncotype DX is widely accepted and has virtually become standard of care for many oncologists. This diagnostic procedure has clearly established clinical value
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested inpatient psychiatric hospital services for treatment of the enrollees behavioral health conditions.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient could have been managed at a lower level of care; her only issue was anger at not being discharged.  This anger led to a seclusion and restraint.  The patient reported that she was not suicidal.  Given her diagnosis of autism spectrum disorder, it is reasonable that she often misunderstands social cues and interactions.  This type of social skills deficit is better addressed in an ongoing social skills group.  The current medical evidence does not support inpatient level of care in this clinical setting.  All told, psychiatric hospital services were not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Ice compression sleeve (pneumatic compressor, non-segmental home model HCPCS code EO650RR). Findings:  The physician reviewer found that patient was being treated for unilateral primary osteoarthritis of the left knee. She underwent robotically assisted left total knee arthroplasty. She utilized an ice compression sleeve. However, there are limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and safe treatment for the noted pathology. Kwiecien and McHugh noted that cryotherapy can be utilized as a physical intervention in the treatment of injury and exercise recovery. Traditionally, ice is used in the treatment of musculoskeletal injury while cold water immersion or whole-body cryotherapy is used for recovery from exercise. Kunkle and colleagues reported that there is a lack of consensus whether the use of continuous cryotherapy devices leads to superior outcomes when compared with treatment with ice packs. This patients records lack detailed documentation of significant increased risk of deep vein thrombosis (DVT) or documentation that compression stockings and/or pharmacologic treatments cannot be utilized. Therefore, the ice compression sleeve (pneumatic compressor, non-segmental home model HCPCS code EO650RR) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the ice compression sleeve (pneumatic compressor, non-segmental home model HCPCS code EO650RR) was 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 device 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: Physician reviewer 1 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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

The parent of a six-year-old male has requested individual home-based speech therapy for treatment of his autism. Findings:  The physician reviewer found that children with autism have deficits in speech and language, as well as social communication. Fundamental to the diagnosis of autism spectrum disorder (ASD) are deficits in speech and language. The majority of children with ASD will benefit from therapies designed to improve their ability to communicate and engage in social interactions. Research has demonstrated that intervention makes a difference, and that early intervention focused on communication and social skills can significantly improve the outlook for individuals on the autism spectrum. The current medical evidence supports the requested therapy in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

A 60-year-old female enrollee has requested for the medication Flomax for treatment of her bladder outlet obstruction. Findings:  The physician reviewer found that there is literature support for the use of alpha blockers in women with bladder outflow obstruction. However, in this clinical situation, the use of Flomax was not medically necessary as there is an absence of medical literature supporting its use over the alpha blockers.
Appeal type: Experimental/Investigational
Decision: Upheld

A 59-year-old male enrollee has requested for CyberKnife stereotactic radiosurgery for treatment of his metastatic cholangiocarcinoma to the left ilium. Findings:  Three physician reviewers found that based on the studies performed to date, there is no clear advantage to using CyberKnife stereotactic radiosurgery in terms of dose escalation, retreatment of the same area with radiation therapy or protection of nearby very sensitive organs at risk. Radiofrequency ablation can also be quite effective in this type of diagnosis.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Flexitouch pneumatic compression device (E0652) and segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668). Lymphedema is a complication associated with treatment for breast neoplastic disease (Doscher, et al.). Treatment options for lymphedema include various physiotherapeutic interventions, skin care, and compression bandaging (Merchant and Chen). Once a patient achieves an initial stage of limb volume reduction, maintenance management can include self-directed exercises, compression garments, and intermittent pneumatic compression devices used in the community. However, there is a paucity of studies demonstrating reduced cellulitis rates and treatment needs with significantly improved outcomes with the addition of intermittent pneumatic compression pump therapy. The addition of trunk appliances on intermittent pneumatic compression pump devices have not been shown to improve patient health outcomes in this clinical setting. Accordingly, the requested Flexitouch pneumatic compression device (E0652) and segmental pneumatic appliance for use with pneumatic compressor, full arm (E0668) are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization for 10 additional sessions of transcranial magnetic stimulation (TMS) therapy. Transcranial Magnetic Stimulation (TMS) is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning 4 to 6 weeks. According to the summary of TMS treatment recommendations in recent literature, the standard parameter setprovided clinical benefit in treatment courses up to 6 weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established.  At this time, there are no adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. Thus, the medical literature does not support a reasonable expectation that additional TMS therapy at this time would improve the patients condition or prevent a more serious episode of illness. Further, the medical record does not include a longitudinal inventory of relevant clinical factors related to the TMS therapy or report of current status. Thus, it would be speculative to assert the necessity of additional treatment at this time. Therefore, the requested 10 sessions of transcranial magnetic stimulation (TMS) are not medically necessary for 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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Stimwave peripheral nerve stimulator implant device.Findings:  Three physician reviewers found that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While there has been progress made in the field of peripheral nerve stimulation over the past two decades, the literature on peripheral nerves that is not associated with headaches consists of case series and individual case reports. The literature is silent on this particular combination of peripheral nerves and the efficacy of peripheral nerve stimulation on the right hip femoral and obturator articular branch nerves. Under these circumstances, a Stimwave peripheral nerve stimulator implant device is not likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the requested service is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are actively practicing and are board certified in anesthesiology, with subspecialty certification in pain medicine. 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.