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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX Breast DCIS Score Assay (CPT 0045U) provided by Genomic Health. This patient has estrogen receptor (ER) and progesterone receptor (PR) positive left breast ductal carcinoma in situ (DCIS). According to the National Comprehensive Cancer Network (NCCN) guidelines, standard of care treatment includes breast conservation therapy followed by whole or partial breast radiation, or total mastectomy with or without sentinel node biopsy. However, there is a paucity of data demonstrating the clinical utility of the Oncotype DX in lieu of standard risk profiling for evaluation of this patients risk for recurrence or development of ipsilateral breast cancer. All told, the Oncotype DX Breast DCIS Score Assay (CPT 0045U) provided by Genomic Health 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 Oncotype DX Breast DCIS Score Assay (CPT 0045U) provided by Genomic Health 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 evaluation 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 genetics 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 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.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  All told, the requested treatment with Harvoni for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. 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 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 patient is a 15-year-old male with an ACL tear. He is scheduled to undergo ACL reconstruction in April 2006 and his orthopedic surgeon has prescribed a CPM machine as part of his postoperative rehabilitation. The patients parent has requested authorization and coverage for the rental of the device. The Health Plan denied the request based upon their determination that the CPM machine is not medically necessary following the patients surgery. A CPM machine is commonly prescribed by surgeons for postoperative rehabilitation following ACL reconstruction. Patient compliance appears to be high and many surgeons find that patients regain their range of motion faster and have better pain control with the device. The orthopedic community recognizes the benefit of early range of motion following this type of surgery and the use of the device postoperatively is medically appropriate. Therefore, I have determined the requested device is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 17-year-old male enrollee has requested residential treatment for treatment of the enrollees cannabis dependence and alcohol abuse. Findings:  The physician reviewer found that this patient had escalating substance abuse for the past several months.  He was unsuccessful in treatment on an outpatient basis and in a wilderness treatment program as well.  During his treatment, he admitted to many of the behaviors that his mother had suspected him of prior to treatment.  He admitted that his substance use was also likely worse than anyone had suspected.  It appears he had not adequately dealt with the death of a close family member, and this was causing continued stress and substance abuse. Per the submitted documentation, the patient had improvement in his symptoms during treatment at the residential treatment center. In cases such as this, an evidence-based, objective, instrument such as the Child and Adolescent Level of Care Utilization System is indispensable in determining the necessary level of care for children and to insure the level of care meets individual needs in the least restrictive setting possible.  Per these guidelines, non-secure 24-hour psychiatric monitoring was medically indicated at the time of admission.  Thus, the patient met criteria for residential treatment services at the time of admission. The patient made progress in treatment and after approximately eight weeks was no longer reporting any mood symptoms.  He also has a history of failed treatments in the past at an outpatient level of care. However, he had no attempts at less restrictive settings, such as an intensive outpatient program. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible.  Based upon the submitted documentation, the residential treatment center level of care was the least restrictive setting indicated for his treatment from the date of admission for approximately eight weeks. As of the following day, this patients mood stabilized, and it appears he could have transitioned to a less restrictive setting.  Thus, residential treatment provided from the admission date for approximately eight weeks was medically indicated.  Residential treatment was not medically indicated from the following date of service through the discharge date.
Appeal type: Medical Necessity
Decision: Upheld

A female enrollee requested anterior cervical disc fusion (cervical spine fusion C6-7) for medical treatment of her neck pain and previous anterior cervical discectomy with fusion (ACDF) at C5-6.   Findings:  The physician reviewer found that the C6-7 segment shows no evidence of pathology. There is no disc herniation, no canal or foramen stenosis, no tumor, infection, fracture, or evidence of adjacent segment disease. Further, the patient does not meet criteria for a cervical fusion (Nikolaidis, et al). She lacks cervical radiculopathy/myelopathy, spinal cord or nerve root compression, infection, fracture, tumor, pseudarthrosis, or adjacent segment degeneration. There is no evidence of a cervical anomaly of a cervical bone. There is no correlation of her imaging studies with her clinical condition. There is no evidence she has failed conservative treatment. The requested anterior cervical disc fusion (cervical spine fusion C6-7) is not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vemlidy 25 mg 1QD for 12 months for treatment of the enrollees chronic hepatitis B virus. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg 1QD for 12 months is medically necessary for the treatment of this patients chronic hepatitis B. 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for rituximab. In the medical literature, the use of rituximab is considered a standard of care in the treatment of autoimmune hemolytic anemia (AIHA) when patients are unable to be weaned below 15 mg per day of prednisone. This patient endorses fatigue and dyspnea on exertion that started in 2018, and has not improved. This patients provider recommended treatment with rituximab and pre-splenectomy vaccinations. A clinic note states the patients hemoglobin is improving while on prednisone. However, she has required at least 15 mg of prednisone daily or more to maintain her hemoglobin. She has evidence of only mild hemolysis as her hemoglobin, MCV, and bilirubin have all improved. Her hemoglobin has only dropped slightly in four weeks from 12.7 to 12. For these reasons, rituximab is likely to be more beneficial than any available standard therapy for treatment of this patient than any available standard therapy. Final Result: Two of the three reviewers determined that the requested medication 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:  One reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing.  One Reviewer is board certified in oncology with subspecialty certification in hematology and is 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 shoe inserts for treatment of the enrollees flat foot.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. In this case, the patient complains of painful feet and the physical exam demonstrates overpronation with a pes planus foot structure. Based on the documentation submitted for review, the patient has poorly functioning biomechanics. Orthotics have been a long-standing, standard of care treatment for painful pes planus with overpronation. For this reason, the recommended shoe inserts are medically necessary for 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Dupixent syringes 300 mg/2 mL. Atopic dermatitis is a complicated immunologic disorder that primarily involves TH2 helper cell dysfunction. Dupixent is a monoclonal antibody targeted therapy that significantly reduces disease and associated symptoms. As topical agents require application to affected areas, in widespread disease, systemic agents are indicated. Compared with conventional immunosuppressive agents, Dupixent has a favorable safety profile and may be used for long-term treatment of atopic dermatitis. This patient presents with atopic dermatitis on a substantial portion of his BSA. His symptoms have persisted despite treatment with corticosteroids. Dupixent is appropriate to treat this patients chronic atopic dermatitis in conjunction with topical agents and non-pharmacokinetic measures. Therefore, the requested Dupixent syringes 300 mg/2 mL are medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A fifty-three year-old obese female with significant comorbid conditions is requesting reimbursement for a duodenal switch procedure.Reviewers Findings:  The reviewing physician found that this patient clearly met the criteria set by the National Institutes of Health for surgical treatment of obesity with a high BMI and co-morbid conditions.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the laboratory testing for antibodies for adalimumab (CPT code 84999). In this case, Anser ADA was performed to direct the management of the patients collagenous colitis. Based on current peer-reviewed medical literature, the use of Anser ADA has not been proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action is not supported in the scientific data. The American Gastroenterological Association (AGA) guidelines for the treatment of collagenous colitis have not included the Anser ADA test in their recommendations.  The published studies on the use of anti-adalimumab antibodies and serum levels in other diseases such as inflammatory bowel disease are retrospective and/or observational in nature. One study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibodies and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. For these reasons, the laboratory testing for antibodies for adalimumab (CPT code 84999) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the laboratory testing for antibodies for adalimumab (CPT code 84999) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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 representative of a 46-year-old female enrollee has requested Gleevec for the treatment of the enrollees meningioma. Findings:  The physician reviewer found that meningioma is a rare brain tumor typically treated with radiation and surgery. Various agents have been utilized for metastatic disease outside of the brain with very little proven efficacy. There is limited experience regarding systemic therapy for metastatic meningioma and the current evidence is largely anecdotal. Systemic therapy has only been used in a few patients with recurrent, unresectable malignant meningiomas. The phase II trials citied above involved a combination regimen of hydroxyurea and imatinib mesylate in small numbers of patients with higher grade brain tumors (not meningiomas). Success was limited and it is not possible to discern the value of Gleevec for patients such as this patient based on those studies. There are no published data on the efficacy of imatinib mesylate in meningiomas currently available in the literature.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for (1) a referral to a skin laser specialist, (2) a 585-nm flashlamp pumped pulsed dye laser/CO2 laser specific for scars, and (3) a higher dosage of Kenalog 40 mg. Jin and colleagues report that the management of hypertrophic scars and keloids remains a therapeutic challenge, and that while laser therapy is an emerging minimally invasive treatment that has recently gained attention, the level of evidence for laser therapy as a keloid treatment is low. The authors conclude that further research is required to determine the mechanism of action for different laser systems and to examine the efficacy in quantifiable parameters, such as scar erythema, scar texture, degrees of symptom relief, recurrence rates, and adverse effects. De Las Alas and colleagues report that the efficacy of 585-nm pulsed dye laser in the treatment of hypertrophic and keloid scars may be superior to conventional modalities in improving overall scar appearance, but that results were comparable when scar parameters were evaluated separately. The authors concluded that more parallel comparison trials with standardized methods of treatment and outcome assessment are recommended to evaluate long-term treatment effects and recurrence rates. In this case, as the patient has only received two rounds of Kenalog, (1) a referral to a skin laser specialist is not medically necessary for the treatment of this patient. Given the lack of evidence in current medical literature supporting the benefit of laser therapies, either pulsed dye laser or ablative carbon dioxide lasers, in the treatment of keloids, (2) a 585-nm flashlamp pumped pulsed dye laser/CO2 laser specific for scars is not medically necessary for the treatment of this patient. In a systematic review of invasive and noninvasive treatment modalities for hypertrophic scars, Kafka and colleagues reported that intralesional injections of 5-Fluorouracil mixed with a low dose of triamcinolone were the most appropriate treatment modality. In this case, a stronger dose of triamcinolone injection may be medically indicated as long as the patient is aware of and understands the increased potential for atrophy. Therefore, (3) a higher dosage of Kenalog 40 mg is medically necessary for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services and medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

A 54-year-old female enrollee has requested Neumega (oprelvekin) for the treatment of her cholangiocarcinoma. Findings:  The physician reviewer found that Neumega is a growth factor used only in rare situations to prevent severe thrombocytopenia from chemotherapy. For the most part, it is used when a prior chemotherapy cycle has already been demonstrated to lower the platelet count severely, (i.e., in the 20,000 range). Such is not the case with this patient, as the lowest platelet count seen (at least reported in the provided records), was 83,000, which is considered a relatively moderate impact on the platelet count. Thus, there is no evidence that the Neumega is medically necessary to continue the chemotherapy in this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for consultation with a transplant hepatologist and blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)).The patient has risk factors for metabolic liver disease, including prediabetes and elevated triglycerides. According to Kwo and colleagues, a workup for underlying liver disease is appropriate given the risk of eventual cirrhosis with untreated metabolic liver disease, and the need to intervene on modifiable liver disease before the development of cirrhosis or end-stage liver disease. All of the requested blood tests (lipoprotein, anion gaps, bilirubin, albumin and total protein, alkaline phosphatase, gamma-glutamyl transferase (GGT), and prothrombin time (PT)) are used in the assessment of liver disease, liver disease activity, hepatic function, or liver fibrosis level. However, the patient does not have an indication for consideration of liver transplantation, and there is no evidence of liver disease on extensive laboratory testing. For these reasons, the requested blood tests are medically necessary for the evaluation of the patients medical condition. However, the consultation with a transplant hepatologist is not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that some of the requested services are 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 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.