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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  The physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were extremely dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast tomosynthesis was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: All three reviewers determined that the  service at issue was 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 number one, two and there are board certified in diagnostic radiology and 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

A 32-year-old female enrollee has requested for the medication Xifaxan 550mg for treatment of her history of constipation and abdominal distension. Findings:  The physician reviewer found that the American College of Gastroenterology position statement regarding the use of non-absorbable antibiotics such as Xifaxan, noted that there is a lack of data available supporting the long-term safety and effectiveness of these non-absorbable antibiotics for the management of irritable bowel syndrome symptoms. The current medical evidence does not support the use of Xifaxan in this patients case. The documentation fails to establish the medical necessity of the medication at issue in this clinical situation.
Appeal type: Medical Necessity
Decision: Overturned

A male enrollee requested a 12-week course of Harvoni for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that Harvoni is the preferred drug for this patient due to the potential for interactions between Viekira Pak and Atripla.  Patients co-infected with HIV should be prioritized for treatment.  As noted by Rockstroh and colleagues, highest priority patients include those with substantial fibrosis, HIV co-infection, diabetes mellitus and coexisting liver disease.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Supartz injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the medical evidence supports the requested services in this clinical setting.  Evidence based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections.  In this case, the patient has been diagnosed with osteoarthritis of both knees.  Ongoing self-care measures have included medications, activity modification, and stationary bike.  He has undergone prior series of viscosupplementation approximately every six months in 2015 and 2016, with reported symptomatic relief of his chronic osteoarthritis pain.  He does not want to proceed with knee replacements at this time.  There is sufficient support for the requested services in this clinical setting.  Therefore, Supartz injections are medically indicated for the 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.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested a second opinion with a craniofacial team/craniofacial reconstructive surgeon for evaluation of the enrollees skull deformity.  Findings:  The physician reviewer found that Kung and Sloan provide a description of frontometaphyseal dysplasia and its treatment, which includes reshaping of the frontal bone or a cranioplasty. The patient described in their study had clear exam findings of a bony supraorbital ridge for which the above treatment options were provided. In the case of the patient involved in this appeal, given his history of craniotomy for a similar condition and the unclear exam findings, his case would warrant a second opinion. The patient underwent an initial surgical procedure and now questions whether he needs a second procedure. The patient has received an initial opinion from plastic surgery; however, there is no evidence of a second plastic surgery opinion in the documentation provided. The first opinion from the plastic surgeon appears to address the need for further surgical intervention adequately, but there is no evidence of a second opinion to confirm his findings. Although the patient has requested a referral to a craniofacial team/craniofacial reconstructive surgeon, plastic surgeons are trained to evaluate craniofacial deformities and therefore a referral to a craniofacial specialist is not necessary. A board certified plastic surgeon will be able to appropriately evaluate the patients condition and make recommendations for future treatment, if required.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old woman has a lesion of her lower right leg/ankle, which was biopsied by her primary care physician in September 2003. The diagnosis by pathology was superficial basal cell carcinoma. The patient has requested authorization for a consultation with a dermatologist for evaluation and treatment of her condition. The Health Plan has denied the patients request on the basis that the initial evaluation and treatment of dermatologic conditions as well as skin surveillance for skin cancer are within the scope of practice and clinical expectation of the patients primary care physician.Generally, dermatologists are better qualified and more knowledgeable and experienced in treating skin cancers and evaluating possible skin cancers. Though the Health Plan indicates that evaluation and treatment of dermatologic disorders, as well as skin surveillance for skin cancer, are within the scope of practice and clinical expectation of a primary care physician, there is no evidence of peer-reviewed studies supporting this contention. Consultation with a dermatologist for evaluation and treatment is medically reasonable and appropriate. Therefore, I have determined that the requested consultation is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-UM uveal melanoma gene expression profile assay for evaluation of the enrollees uveal melanoma. Findings:  2/3 of the physician reviewers found that DecisionDx assay is a study of 15-31 genes in an individual patients melanoma cells. DecisionDx has been used to classify the melanoma as either a high or low risk of metastasis. While DecisionDx remains controversial for use in cutaneous melanoma, it does appear to be useful in the analysis of uveal melanoma as noted by the American Joint Committee on Cancer (AJCC) and in clinical studies from colleagues. Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis. For use in this clinical setting, the DecisionDx assay has become the standard of care in many ocular cancer centers to determine the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy. For these reasons, the DecisionDx-UM uveal melanoma gene expression profile assay provided 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 testing at issue was 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 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: Overturned

The patient is a 53-year-old female with a body mass index (BMI) of 56.2 and significant comorbid conditions. Additionally, she has motility and obstructive problems resulting from her gastric stapling over 25 years ago.  The patient has completed a psychological evaluation and was deemed an acceptable candidate for weight loss surgery. The Health Plan has denied coverage for revisional gastric bypass surgery based upon their determination that the procedure is not medically necessary for treatment of the patients morbid obesity and gastrointestinal problems.With a BMI of 56.2 and comorbid conditions such as gastric stasis, depression, gastroesophageal reflux disease, obstructive sleep apnea, hypertension, diabetes mellitus, venous insufficiency, and degenerative joint disease the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. The gastrointestinal problems described by the patient are not uncommon following vertical banded gastroplasty (VBG) or the gastric stapling operation. The patient should fully explore all of the surgical weight loss options available for the procedure, and it is probable that revisional surgery will be beneficial for her. There is no clinical data that supports a requirement of a pre-operative weight loss of 5% of total body weight.  Furthermore, there is no scientific evidence demonstrating that structured diet or exercise plans have been successful in the treatment of the morbidly obese. In fact, the Swedish obesity study identifies that even though there may be reduction or resolution of some symptoms with diet and exercise, surgery has the longest and best long-term outcome for the morbidly obese. An anti-dumping diet has not been shown to be a factor in the success or failure of gastric bypass surgery.  The psychological evaluation indicates the patient is an appropriate candidate for the surgery.Based upon the information set forth above, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for two individual therapy sessions per month with a Psychiatry Department therapist for the treatment of depression. Findings:  The physician reviewer found that According to the American Psychiatric Association, patients with co-occurring depression and substance use disorder are more likely to require hospitalization, more likely to attempt suicide, and less likely to adhere to treatment than patients with affective illness uncomplicated by substance abuse. In this case, the patient has not fully responded to the standard intervention provided by the Health Plan, and it appears that he has not been referred to a psychologist or psychiatrist for a diagnostic evaluation during this episode of illness. The patient has expressed a reasonable preference for psychotherapy to augment his chemical dependency treatment services. There is support for the requested services in this clinical setting. Specifically, a time-limited course of an evidence-based therapy is safe, appropriate, consistent with practice standards, and is reasonably expected to improve the patients condition. In sum, a course of eight individual therapy appointments delivered once every other week with systematic monitoring and re-assessment of clinical needs upon conclusion of the treatment episode is medically necessary. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.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 mother of a 13-year-old female enrollee requested authorization and coverage of inpatient treatment services.The Health Plan denied the enrollee's request indicating that the requested treatment is not medically necessary for treatment of the enrollees behavioral health problems.  One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the Health Plans denial on the basis that the requested services are medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

A female enrollee requested the MammaPrint, TargetPrint, and BluePrint testing for medical evaluation of her history of invasive and in situ ductal carcinoma.  Findings:  Three physician reviewers found that the MammaPrint assay is a fairly reliable predictor of risk of recurrence in women with early breast cancer, following surgical resection. MammaPrint can be used to identify a subset of women in whom risk of recurrence is low, and as such, can be spared adjuvant chemotherapy (Buyse, et al). These were the circumstances that the MammaPrint assay was appropriately utilized in this case, and as such the test was likely to have been more beneficial for evaluation of this patients medical condition than any available therapy.  However, the TargetPrint and BluePrint assays were not likely to have provided additional data relevant to determining whether the patient should be treated with adjuvant chemotherapy. Thus, the MammaPrint, testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the TargetPrint and BluePrint assays were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 57-year-old male has requested Minimally Invasive 5 Box Maze for treatment of his atrial fibrillation.  Findings:  Two physician reviewers found that the patient has a history of very symptomatic paroxysmal atrial fibrillation that has been refractory to anti-arrhythmic medications and three prior percutaneous ablation procedures.  In this clinical setting, the requested Minimally Invasive 5 Box Maze is likely to be more efficacious than other treatment alternatives.  This patient has continued symptomatic atrial fibrillation that has been refractory to medication and percutaneous catheter ablation.  As noted by Sirak and colleagues, the requested procedure performed minimally invasively through a thoracoscope has been shown to have favorable preliminary efficacy and safety data compared to historical controls of the standard surgical Maze procedure.  There is sufficient evidence in the scientific literature demonstrating the long-term safety and efficacy of the requested Minimally Invasive 5 Box Maze in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 13-year-old male and the full sibling of a sister with mental retardation, dysmorphic features and congenital anomalies. The sister has a chromosomal abnormality consisting of a deletion of the short arm of chromosome #8 from p22 to p terminal. Karyotypes were performed on both of the parents using peripheral blood and no abnormalities were identified. The parents were counseled by a clinical geneticist who advised them that the healthy siblings did not require chromosomal studies since the youngest childs abnormal karyotype arose de-novo as a new mutation. Nonetheless, the enrollees parent has requested authorization for genetic testing for the patient. The Health Plan denied the request based upon a determination that the testing is not medically necessary.The patients sister has congenital heart disease, mental retardation and dysmorphic features which are compatible with her abnormal karyotype 46XXdel(8)(p22). The patients mother has a normal female karyotype in blood, 46XX, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). The patients father has a normal male karyotype in blood, 46XY, with no evidence to support a rearrangement that could lead to the abnormal karyotype 46XXdel(8)(p22). These normal parental karyotypes support the opinion that the youngest childs chromosomal abnormality arose as a de-novo mutation. The enrollee is a normal and healthy male without any signs suggestive of a chromosomal anomaly. Chromosomal studies are not indicated for him at this time. Based upon the information set forth above, I have determined the requested testing is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old female enrollee has requested speech therapy two times per week and sensory integration occupational therapy one time per week for treatment of the enrollees autism. Findings:  The physician reviewer found that the need for speech therapy for this patient with autism is clearly illustrated in the records provided for this review. Speech and language therapy is an essential component in the treatment of young patients with autism. Specifically, speech therapy has been shown to be beneficial and necessary in improving communication in children with autism. According to Myers and colleagues, most children with ASDs can develop useful speech, however, traditional, low-intensity pull-out service delivery models are often ineffective, and speech-language pathologists are likely to be most effective when they train and work in close collaboration with teachers, support personnel, families, and the childs peers to promote functional communication in natural settings throughout the day. As such, this patient should continue to receive services through the school with additional individual speech therapy authorized by the Health Plan to allow for the inclusion of other caregivers and settings.With regard to the request for once weekly sensory integration occupational therapy, the submitted records currently do not document delays that are likely to be benefit from this therapy. The Health Plan recommended the patient undergo an evaluation for sensory integration occupational therapy to determine the medical necessity of these services. Given the lack of evidence demonstrating the need for sensory integration therapy at this time, the alternative service recommended by the Health Plan is medically reasonable and appropriate.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a four-dimensional (4D) computed tomography (CT) scan of the neck. Primary hyperparathyroidism is often found in clinical practice with resultant hypercalcemia. Imaging tests help to confirm the condition, but a negative scan does not rule out the diagnosis. Sestamibi scintigraphy is an acceptable method for localizing a solitary parathyroid adenoma. However, the technique alone does not reliably predict multi-glandular disease. The utility of sestamibi parathyroid imaging is limited by an approximate 20% false-negative rate and is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multi-glandular disease, superior adenomas, or preoperative normocalcemia. In this patients case, a 4D CT scan has higher sensitivity in terms of localizing a parathyroid adenoma. Therefore, the requested 4D CT scan is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification diabetes, endocrinology 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

A 26-year-old female enrollee has requested artificial intervertebral disc replacement surgery for the treatment of her lower back pain. Findings:  Three physician reviewers found that lumbar artificial disc replacement is still experimental for the treatment of lumbar degenerative disc conditions. There are no long-term outcomes studies to establish the safety and efficacy of the procedure and complications are not well defined. More quality outcomes data is needed to establish the effectiveness of this procedure in the long term. Fusion or non-operative management remains the gold standard treatment and standard of care.