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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for tilt table testing services. Findings:  Two of the three physician reviewers found that the medical evidence supports the services at issue in this clinical setting. This patient has a history of headaches which have been unresponsive to multiple interventions. Headaches are a common symptom associated with postural orthostatic tachycardia syndrome, especially in adolescents. Assessing this patient with recurrent persistent migraine for postural orthostatic tachycardia syndrome was appropriate based on published data. Tilt table testing is the recommended modality for diagnosing postural orthostatic tachycardia syndrome. Therefore, tilt table testing services were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 60-year-old female enrollee has requested for the Oncotype DX tumor assay for evaluation of her breast cancer. Findings:  The physician reviewer found that the Oncotype DX tumor assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score. This score quite accurately predicts the risk of recurrence of the cancer within ten years, if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay is valid only in node-negative, estrogen-receptor-positive cancers. It is particularly difficult to make recommendations about adding adjuvant chemotherapy in this group of breast cancer patients, and Oncotype DX testing has become very important. The assay has been rapidly adopted by many oncologists as part of their standard evaluation and Medicare has approved its use.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for right first metatarsophalangeal joint (MTP) joint synthetic cartilage implant surgery (CPT 28291). Baumhauer and colleagues performed a prospective, randomized, controlled, non-inferiority clinical trial to compare the safety and efficacy of a synthetic cartilage bone implant to first MTP arthrodesis in patients with advanced-stage hallux rigidus. The authors demonstrated equivalent pain relief and functional outcomes over two years. The authors concluded that synthetic implants are an excellent alternative to arthrodesis in patients who wished to maintain first MTP motion. This patient presented with a history of chronic right great toe pain with functional limitations. Clinical examination findings documented bony proliferation around the first MTP joint of her right foot, joint effusion, and painful limited dorsiflexion with crepitus. There was radiographic evidence of complete loss of joint space, cystic degeneration of the head of the metatarsal and bony proliferation over the dorsal aspect of the joint. She underwent right first MTP joint synthetic cartilage implant surgery. The provider noted that the patient did not want a fusion procedure. Evidence based medical literature supports the use of a synthetic cartilage implant as an option in this enrollees medical condition to maintain first MTP joint motion. A Level 1 prospective randomized study demonstrated the safety and efficacy of MTP joint synthetic cartilage implant surgery as an alternative to arthrodesis at two years (Glazebrook, et al.). Given these findings, the right first MTP joint synthetic cartilage implant surgery (CPT 28291) was 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 right first MTP joint synthetic cartilage implant surgery (CPT 28291) was likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old female enrollee has requested a magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her back pain. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested diagnostic study. A lumbar MRI may be performed to evaluate low back pain that does not get better after treatment, or lower leg weakness, numbness, and other symptoms that do not improve. A physician may also order a lumbar MRI if the patient has back pain and fever, birth defects of the lower spine, injury or trauma to the lower spine, low back pain with a history of cancer, multiple sclerosis, problems controlling or emptying the bladder, or disc herniation. In this case, the patient does not exhibit any signs or symptoms suggestive of significant spinal pathology. The patient demonstrates normal range of motion with normal strength, normal gait, and normal reflexes. The medical necessity for a lumbar MRI scan has not been established. Based on the medical literature cited above and the documentation submitted for review, the requested diagnostic study is not medically necessary for evaluation of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a five-year-old male enrollee has requested  speech therapy for treatment of the enrollees speech disorder and hypernasality secondary to a history of cleft lip and palate. Findings:  The physician reviewer found that as children age, the speech pathologist is essential in evaluating skills and determining if therapy is indicated for correction of speech sound production (articulation) errors. The goals are to establish the correct placement of the oral structures for speech sound production and directing the airflow appropriately. Goals are set depending on the error patterns and the age of the child. It should be kept in mind that errors due to structural defects cannot be corrected through speech therapy unless the structural deformity is corrected. Also, the structural correction should be followed with speech therapy to correct the functioning/production of speech sounds. Appropriate feedback during therapy using multiple modalities such as auditory, visual, and tactile techniques is extremely important in the management of articulation and resonance disorders (Nagarajan and colleagues).This patient with a history of cleft lip and palate status post repair has been involved with speech and language therapy in the past with improvement in skills. However, because of the limited intervention, he was not able to maintain and generalize those skills. A recent re-evaluation was performed, and additional therapeutic intervention was appropriately recommended based on the patients documented deficits.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of her chronic pain. The physician reviewer found that although opioids are routinely used in chronic pain management, there is a lack of data demonstrating significant efficacy with their use on a long-term basis. After receiving hydrocodone for a short period of time, many patients become long-term or lifelong users. Consequently, hydrocodone is not indicated for routine pain management as in this clinical setting. All told, the requested Norco is not medically necessary for this patients chronic pain management. 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: Upheld

The parent of an enrollee has requested authorization and coverage for individual dialectical behavior therapy (DBT) twice a week. A Cochrane review of therapeutic interventions for addressing self-harm in children and adolescents concluded that there have been relatively few investigations into interventions for children and adolescents who engage in self-harm. The review concluded that there is little evidence on which to draw conclusions on the effectiveness of interventions for self-harm in this population. While there were some very limited positive findings regarding DBT-A (DBT for adolescents), mentalization, and therapeutic assessment, the review concluded that these approaches require further evaluation before any definitive conclusions about their use in clinical practice can be made. In this case, the patients diagnoses include depression and anxiety, and her symptoms include suicidality and self-harm. Given the lack of evidence that dialectical behavior therapy (DBT) is effective for patient's diagnoses and symptoms, including depression, anxiety, and self-harm, the requested individual dialectical behavior therapy (DBT) twice a week is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that requested services are not medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be upheld.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: Upheld

A 58-year-old female enrollee has requested an abdominoplasty/ panniculectomy for treatment of her condition. Findings:  The physician reviewer found that there is a lack of documentation of uncontrolled intertigo that has not been responsive to conservative management over a period of time.  There are no medical records demonstrating the presence of a ventral hernia documented on imaging. There is a lack of documentation that the patients weight loss is the cause of the panniculus.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 66-year-old female who is status post vertical banded gastroplasty (VBG) with subsequent weight regain. At present, her BMI is 48 and she has obesity related comorbidities such as type 2 diabetes, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and depression. She has had some transient weight loss with diet.  Upper GI series and endoscopy suggests that the VBG has broken down.  The patient has completed a psychological evaluation and was deemed an appropriate candidate for weight loss surgery. The patients provider recommends gastric bypass surgery and has submitted a request for authorization.  The Health Plan denied the request citing a lack of medical necessity.With a BMI of 48 and comorbid conditions such as type 2 diabetes, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and depression, the patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Weight regain after VBG is not uncommon, especially given the lack of dumping. It is appropriate to convert a failed VBG to a Roux-en-Y gastric bypass under these circumstances.  It is highly likely that the gastric bypass surgery will be beneficial for this patient. Furthermore, the patient does not require further dietary workup prior to undergoing weight loss surgery. 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.  The psychological evaluation indicates the patient is an appropriate candidate for the surgery.Based upon the information set forth above, I have determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, 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 gene testing (MyRisk CPT 81479). Findings:  The physician reviewers found that this patients history is suggestive of a potential de novo mutation in her sister or predisposition to cancer with variable penetrance. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. These are the Amsterdam criteria and the Bethesda consensus guidelines. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed. However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this case, the MyRisk panel was medically appropriate since the patients clinical situation may be caused by several potential cancer-causing genes. Therefore, the gene testing (MyRisk CPT 81479) performed  was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance imaging for evaluation of the enrollees headaches. Findings:  The physician reviewer found that evidence based medical guidelines support MRI of the brain in this clinical setting. The National Imaging Association (NIA) clinical guidelines specify MRI of the brain for headaches lasting more than a few minutes when there is associated neck pain. These types of headaches could be related to carotid/vertebral artery dissection.  In this case, the patient presented with a unilateral severe headache which lasted one week. Moreover, the records indicate that while the neurological examination was normal, there was a concern of intracranial pathology. The patient did not have signs of sinus disease and there was no history of infection or trauma reported. Based upon the patients history and the referenced guidelines, the services at issue were medically appropriate. As such, the MRI was medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Medical Necessity
Decision: Overturned

A 59-year-old male enrollee requested revision sinonasal surgery for treatment of the his chronic sinusitis.  Findings:  The physician reviewer found that submitted documentation and relevant literature demonstrates the medical necessity of the requested procedure. The patient has evidence on CT scan imaging of a persistence of the opacification of the frontal sinus. According to the clinical records, the patient has had at least two consultations with ear, nose and throat specialists who are in agreement that revision sinus surgery is indicated for treatment of his condition.   Based on the documentation submitted for review, the medically necessity for the requested procedure has been established.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liver transplant (CPT 47135). This patient has a metastatic neuroendocrine tumor (NET) with involvement of numerous liver metastases, mass in the tail of the pancreas, ascites and possible lymph node involvement. Although this patient has a well-differentiated tumor, the patient also has several risk factors for recurrence or inferior survival including symptomatic tumor, a primary tumor in the pancreas, and greater than 50% involvement of the liver. The patient may have extrahepatic spread as noted by ascites and lymphadenopathy (Moris, et al.). Liver transplantation has been used in the past for patients with isolated metastases to the liver with mixed results. The proposal in this case is for living donor liver transplantation. Fan and colleagues performed a metanalysis of the literature of liver transplantation for patients with NET. The authors reported no difference in five-year survival of transplanted patients when compared to non-transplanted patients. However, there is a lack of clinical data demonstrating that living donor liver transplant is superior to deceased donor liver transplant. Given these findings, the requested liver transplant (CPT 47135) is 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 requested liver transplant (CPT 47135) is 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 requested services are 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 surgery and is actively practicing. Physician reviewer 2 is board certified in surgery with expertise in kidney, pancreas and liver transplantation and is actively practicing. Physician reviewer 3 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.Findings: There is a lack of support for the services at issue in this clinical setting. This patient has been diagnosed with an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended. In sum, DecisionDx-Melanoma assay was not likely to have been of greater benefit than other available modalities for evaluating this patient.Final Result: The reviewers determined that DecisionDx-Melanoma assay was likely to be more beneficial than the available standard therapy for evaluation of patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.