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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne CDx comprehensive genomic profiling test. Genetic or mutational testing is informative for patients with metastatic colorectal cancer since it can help direct therapeutic decisions. Knowledge of tumor mutations figures prominently in the work-up of metastatic colon cancer in the NCCN guidelines. Specifically, KRAS and BRAF mutations may inform therapy decisions. KRAS is one of the most frequently mutated oncogenes in colorectal cancer. A mutation in KRAS has been associated with worse progression-free survival (PFS) compared to patients with wild type KRAS when treated with monoclonal antibody directed against epidermal growth factor receptor (EGFR) in combination with chemotherapy. There is published data from a large retrospective trial that the presence of the BRAF mutation provides additional prognostic information with regard to cetuximab treatment. The MEK kinases are within the same pathway as RAS and BRAF. This provides evidence that treatment with dabrafenib, trametinib, or vemurafenib to tumors with constitutive RAS signaling may be effective. One study on 86 patients reported PFS on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. In summary, there are multiple gene mutations with both prognostic and therapeutic utility making the testing reasonable for this patient with a diagnosis of moderately differentiated adenocarcinoma of the colon with extension to the serosal margin. Therefore, the FoundationOne CDx comprehensive genomic profiling test was 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 FoundationOne CDx comprehensive genomic profiling test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty 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

A 23-year-old female enrollee has requested for continued stay at a chemical dependency partial hospitalization program for treatment of her polysubstance abuse. Findings:  The physician reviewer found that Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) level of care utilization criteria and the American, Society of Addition Medicine Patient Placement Criteria for the Treatment of Substance-Related Disorders, dimensions to consider must include functional status, co-morbid conditions, recovery environment and stressors, treatment history, and engagement and readiness for change.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 90 mg-400 mg tablet for 12 weeks. Findings:  The physician reviewer found that according to the 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 hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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 . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, the requested treatment with Harvoni 90 mg-400 mg tablet for 12 weeks is medically necessary for the treatment of the 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center (RTC) services. The records provided for review document that the patient had no significant post-acute withdrawal symptoms, his urine drug screen was negative, and his Clinical Institute Withdrawal Assessment (CIWA) was. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant the RTC level of care. He was medically and psychiatrically stable. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. His vital signs were stable. He was motivated and had some insight into the impact of his alcohol use. The documentation indicates that the patient could have been safely and effectively treated at a lower level of care and did not require 24-hour supervision at RTC level of care. He did not require the structured setting of a RTC. All told, the RTC services provided were not medically necessary for treatment of the patients behavioral health 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 psychiatry with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for thermography for evaluation of the enrollee, who has a history of a breast lump and family history of breast cancer. Findings:  The physician reviewer found that the current medical evidence does not support the requested services in this clinical setting. Breast thermography does not have a role in the primary detection or screening for breast cancer. The American College of Radiology noted there is insufficient evidence to support the use of other imaging modalities, such as thermography, breast-specific gamma imaging, positron emission mammography, and optical imaging, for breast cancer screening.  Breast thermography has been approved by the U.S. Food and Drug Administration only as an adjunct to mammography. A study noted a recent systematic review concluded that there is currently insufficient evidence to recommend the use of this technology for breast cancer screening, with significant heterogeneity identified in published studies for both digital infrared thermal imagings sensitivity and specificity. In this patients case, a palpable lump cannot be ignored, and a repeat mammogram is warranted. She indicates that her prior mammograms have been inconclusive, but that is not the case. Many women have heterogeneously dense breast tissue and do not have breast cancer. In recent years, breast tomosynthesis has become commonplace to evaluate patients in this clinical setting. All told, the requested thermography is not medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for medical evaluation of her breast examination.  Findings:  Two physician reviewers found that researchers found the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Another medical study investigated the effect of integrated 2D and 3D mammography in population breast cancer screening. They found that integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. The literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, upon review of the submitted documentation, the use of breast tomosynthesis for this patient was likely to be more beneficial than 2D imaging alone.   Final Result: Two 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:  One reviewer is board certified in radiology and is actively practicing. Two reviewers are board certified in radiology with sub-specialty certification in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 34-year-old female enrollee requested authorization and coverage of a referral to an out-of-network plastic and reconstructive surgeon for umbilical hernia repair.  The health plan denied the enrollees request indicating that the requested referral is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested referral is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa injections in the left knee. Findings: Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. 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 where everything else has been tried, and the options are limited. In this case, the patient has tried and failed other conservative treatments, such as cortisone injections, with the alternative being a total knee arthroplasty Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore, Euflexxa injections in the left knee are medically necessary 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: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of her chronic pain.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Subsys has not been established. Subsys is not medically necessary in this clinical setting. The current standard of care for chronic pain associated with lower back pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy.  Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. For the reasons provided, the patients request for Subsys is not medically necessary.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether the feeding therapy with sensory integration services that were received were likely to have been more beneficial for treatment of the patients condition than any available standard therapy. A review of the record indicates that the patient has been diagnosed with autism, anxiety, and sensory integration dysfunction. The severity of his sensory aversion and anxiety surrounding food limits his nutrition.One of three physician reviewers found that The American Academy of Pediatrics states that parents should be informed that the amount of research regarding the effectiveness of sensory integration therapy is limited and inconclusive. Researchers performed a meta-analysis and systematic review of the literature on sensory integration therapy. The authors found that the evidence is insufficient to draw conclusions regarding multisensory activities. Therefore, the feeding therapy with sensory integration services that were received was not likely to have been more beneficial for the treatment of the patients medical condition than any standard available therapy. Two out of three physician reviewers found that in this case, learned behaviors that adversely impact ingestion must be approached by modifying the sensory experience itself, which is addressed during sensory integration. Thus, the feeding therapy with sensory integration services that were received were likely to have been more beneficial than any standard available therapy.Final Result: The reviewers determined that the requested test 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: Two physician reviewers are board certified in neurology with special qualification in child neurology, and one physician review is board certified in pediatrics, all three 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica for treatment of the enrollee, who has a history of fibromyalgia. Findings: The physician reviewer found that the American College of Rheumatology recommended preliminary diagnostic criteria for fibromyalgia. These criteria are recommended when assessing the physical and psychological symptoms of patients with fibromyalgia. Specifically, in this patients case, the documentation provided does not indicate that she has a widespread pain index score of at least 7 and a symptom severity score of at least 5. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The stepwise World Health Organization ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Behavior therapy has not been discussed or noted to be completed despite much research to support its use. In addition, the records do not show that all non-opioid medications classes have been optimized or tried. Finally, multiple minimal requirements for controlled substance prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain have not been established in this patients case. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 57-year-old female who was diagnosed with pancreatic cancer in 2004 and underwent a whipple procedure. The tumor was a poorly differentiated adenocarcinoma. Eleven nodes were negative and the closest margin was 1mm.  Perineural invasion was present. The patient underwent chemotherapy and radiation therapy. She has been followed regularly and a CT scan dated March 2006 revealed borderline enlarged periaortic and mesenteric lymph nodes. The patients oncologist has requested a PET scan for further evaluation. The question is whether the PET scan is medically necessary.Prior Centers for Medicare and Medicaid Services (CMS) reimbursement standards did not include pancreatic cancer as one of the listed indications for PET scan.  However, the National Oncologic PET Registry (NOPR) was developed in response to the CMS proposal to expand coverage for PET scans to include cancers and indications that were not previously eligible for Medicare reimbursement. Pancreatic cancer is listed by NOPR for diagnosis, staging, restaging, and monitoring. NOPR is implementing this registry for CMS and the registry has recently opened.The sensitivity of PET in the detection of pancreatic adenocarcinoma ranges from 85% to 100%. A study by Kalra, et. al. concluded PET offers a reliable method of differentiating recurrent or residual tumor from inflammatory or scar tissue, detecting unsuspected metastases, and evaluating pancreatic masses with equivocal CT diagnosis. The information from the PET scan will be helpful to the treating oncologist in planning the patients future management and as such, is medically appropriate and necessary.For the reasons set forth above, I have determined the requested PET scan is medically necessary for evaluation of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 17-year-old male with a history of relatively long-standing use of marijuana beginning at age 12, eventually amounting to an intake of about 1-3 joints per day. In addition, the patient participated in very sporadic use of other drugs such as cocaine and amphetamine since the age of 16. His last use of marijuana occurred in August 2004, the patient thereafter having entered a residential treatment program from September 2004 through November 2004. For reasons not entirely clear, he was thereafter admitted to another residential treatment program in November 2004 where he was diagnosed as suffering from marijuana dependence, alcohol dependence, alcohol abuse, and oppositional defiant disorder. He was noted to have a somewhat contentious relationship with his father, the latter deemed rather demanding and occasionally emotionally abusive. The patient has been principally living with his mother - his parents are divorced. He was also noted as depressed, mainly due to rejection by his most recent girlfriend who cheated on him with several of his close friends, though his depression was otherwise poorly described. He was also thought of as having difficulty contending with his feelings, particularly about family conflicts.He remained in the residential treatment facility from November 2004 through February 2005 and was subsequently admitted to partial hospitalization in March 2005 where he remained until May 2005. He was treated with a number of psychotherapies and periodically saw a psychiatrist, but was not thought to be so depressed as to warrant any antidepressants. The psychiatrist's notes of the patient include descriptors such as