Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Letairis (ambrisentan) and Adcirca (tadalafil) for treatment of the enrollees pulmonary hypertension.Findings:  The physician reviewer found that the management of PAH was initially limited to continuous intravenous infusions of prostacyclin, a difficult drug to administer and tolerate. In the past several decades there has been an abundance of compounds available and methods of administration. The most recent data on the management of PAH comes from the AMBITION study. The authors found that among treatment naive patients, a two drug regimen demonstrated a significantly lower risk of treatment failure than starting drugs individually. Specifically, the study concluded that among participants with pulmonary arterial hypertension who had not received previous treatment, the risk of the composite outcome of clinical failure was significantly lower among those who received initial combination therapy with ambrisentan and tadalafil than among those who received monotherapy with either ambrisentan or tadalafil. In this case, the patient has been recently diagnosed with PAH, and she is treatment naive. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in critical care medicine and pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is insufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, 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. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improve breast cancer detection and have the potential to reduce false positive recalls. However, in this particular patient, the submitted documentation does not indicate that there were problems to be resolved. Although the patient has a family history of breast cancer, medical literature has not shown significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially in view of the extra radiation dose. Based upon the information set forth above, along with peer-reviewed literature, the services at issue were not likely to be more beneficial for evaluation of the patients breast examination than any available standard therapy.   Final Result: Two 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-certification in diagnostic radiology and is actively practicing. Two reviewers are board certified in radiology with sub-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: Experimental/Investigational
Decision: Upheld

A female enrollee requested breast tomosynthesis (CPT 77063) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found there is a lack of peer-reviewed literature that supports the use of 3D breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis is a promising tool in breast imaging, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Therefore, the breast tomosynthesis was not likely to be more beneficial for evaluation of this patient than standard modalities.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested rehabilitation services for treatment of his medical condition. Findings:  The physician reviewer found that adrenoleukodystrophy is pathophysiologically characterized predominantly by a non-inflammatory distal axonopathy involving mostly the long tracts of the spinal cord, resulting in a progressive spastic paraplegia. Current studies state that there is no cure for the leukodystrophies and treatment of the underlying pathology remains challenging. The patients treatment for his adrenoleukodystrophy was complicated by a stroke. He underwent inpatient rehabilitation and was discharged home. Per the submitted records, he has been undergoing rehabilitation in a residential setting. The patient is otherwise mobile at the household level without an assistive device and the community level with crutches. He is performing his self-care tasks with supervision and direction. In sum, the patient did not require continued rehabilitation services. All told, rehabilitation services were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-month-old male has requested coverage for palivizumab (Synagis) injections for treatment of this infant who was born at 32 weeks gestation.  Findings:  The physician reviewer found that Palivizumab injections are medically necessary in this clinical situation.  There are a number of risk factors that increase the chance of morbidity from respiratory syncytial virus (RSV) in infants born at 32 to 35 weeks gestation. The most striking of these is a birth weight less than 2500 grams.  An infant with a birth weight between 1500 and 2500 grams is five times more likely to die from RSV infection than an infant with a birth weight greater than 2500 grams.  Simoes and colleagues have developed a model based on seven risk factors to predict which infants born between 32 and 35 weeks are at highest risk of severe RSV disease.  In this patients case, his risk factors include gestational age and birth weight less than 2500 grams.  Thus, there is a risk of significant morbidity from RSV disease. The Impact-RSV Study Group examined the effect of palivizumab prophylaxis on severity of illness in premature infants. The authors noted a significant decrease in hospitalization rate for all infants.  Of note, for infants born between 32 and 35 weeks gestation that received palivizumab prophylaxis, there was an 80% decrease in hospitalization rate. Palivizumab prophylaxis has shown continued efficacy in reducing severity of illness.  The current medical evidence supports the requested services in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old male enrollee has requested speech therapy for treatment of the enrollees expressive language delay.  Findings:  The physician reviewer found that this patient has an identified delay in expressive speech of greater than 50%. Speech therapy is indicated with any delay greater than 25%. Extensive review of the literature including meta-analysis by Law, et al. noted the positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulty. Feldman, et al. notes that treatment for language disorders is predicated primarily on the childs language profile and level of communication skills. According to the authors, approximately one-half of children delayed at two years catch up to peers by three years of age. Those children with mild to moderate disorders are more likely to resolve their delay compared to those with severe disorders. Children who participate in speech-language treatment show greater improvement than those children who have no treatment. Gallagher, et al. evaluated speech and language interventions for 24 preschool children with specific language impairment. They found statistically greater improvement with intensive direct speech and language therapy delivered by speech and language therapists over an eight-month period when compared to no intervention or nursery-based intervention. As such, speech therapy is medically appropriate and necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for inpatient behavioral health level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The progress notes from the disputed period indicate that the patient had initially improved, and catatonic symptoms were not present.  However, after several days, the patients catatonic symptoms returned.  He was not able to take care of his activities of daily living and was also not eating. During the timeframe when the patient was again catatonic, it does not appear that he could have been treated on an outpatient basis or in a partial hospital program due to his symptoms as well as noted suicidal ideation.  During the last two days of the stay, it appears that he again improved. However, the patient also showed similar improvement during the middle of his status. It appeared reasonable that the patient would need to stay in hospital for the last several days of the disputed period due to the fact that he had decompensated after an initial period of improvement earlier during his stay. The current medical evidence supports the services at issue in this clinical setting. All told, inpatient behavioral health level of care services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 authorization and coverage for Xeljanz 5 mg tablets. Alopecia areata is an autoimmune disorder that causes hair loss in the scalp and can progress to alopecia universalis. This patient has a longstanding history of alopecia areata and he demonstrated worsening of the disease in the last few years. In 2019, he was diagnosed with alopecia areata universalis. Xeljanz treatment was initiated at that time, and he exhibited significant improvement. Due to illness and concerns about immune suppression in the light of COVID-19, the patient ceased therapy. On follow-up, the provider noted that the patient has lost the progress he made with Xeljanz. Upon review of the current peer-reviewed medical literature, it has been noted that aggressive treatment is reserved for patients with a higher percentage of surface involvement. This patient has progressed to alopecia areata universalis, which supports aggressive treatment. Strazzulla and colleagues recommend topical and oral steroids, as well as JAK inhibitors for patients with greater than 50% scalp involvement. This patient previously failed standard therapies. He has a history of significant improvement while on Xeljanz, which is now waning after being off of the medication for about several months. All told, the requested Xeljanz 5 mg tablets are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested Xeljanz 5 mg tablets are 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 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: Physician reviewers 1, 2, and 3 are board certified in dermatology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 63-year-old female enrollee has requested reimbursement for the FoundationOne blood test for evaluation of the enrollees chronic lymphocytic leukemia.  Findings:  The physician reviewer found that Per the National Comprehensive Cancer Network (NCCN) guidelines, patients with CLL with suspected relapse or progressive disease should undergo valuation with Tp53 and FISH chromosomes. Thus, the Tp53 and FISH chromosome portions of the FoundationOne blood testing performed were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the FoundationOne blood test was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of 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 partially overturned.Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Upheld

A 64-year-old female enrollee has requested Botox injections for treatment of her urinary frequency and urge incontinence.  Findings:  Two physician reviewers found that in this patients case, the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The clinical notes do not include a complete medical and urologic history and physical examination supporting the requested services in this case.  Additionally, details regarding the type and duration of prior therapies were not provided.  Although Botox injections may be indicated for the treatment of urinary incontinence due to detrusor overactivity associated with a neurologic condition, there is no documentation of a neurologic condition requiring Botox injections in this case.  Therefore, Botox injections are not likely to be more effective than other treatment modalities in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS). TMS therapy is U.S. Food and Drug Administration (FDA) approved for treating patients in the acute phase of major depressive disorder. There have been some small studies evaluating the use of TMS in bipolar disorder, but the data have not revealed statistically significant remission rates. There are ongoing studies investigating the use of TMS for the depressed phase of bipolar disorder, but not have yet demonstrated evidence that would support the use of TMS for bipolar disorder. This patient has a history of bipolar disorder characterized by episodes of hypomania and depression as well as anxiety. However, TMS is not recommended for the treatment of bipolar disorder based on consensus statements and lack of clinical trials demonstrating long-term safety and efficacy. All told, the TMS treatment provided was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential mental health and substance abuse treatment services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the documentation submitted for review supports the medical necessity of the residential mental health and substance abuse treatment services in dispute. According to the American Psychiatric Association (APA) Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. Considering the patients history of abuse and post-traumatic symptoms, the feasibility and appropriateness of discharge to a sober living environment was questioned by the clinical team. In the absence of residential programming, the patient would have more than likely returned to a pathological and self-defeating pattern of alcohol consumption if she was discharged. The comprehensive services being provided have been delivered in accordance with an individual treatment plan. The services address not only her addictive illness, but her anxiety, depression, pain and family issues as well. Further, the services remain reasonably expected to improve the patients condition and prevent a more serious episode of illness. Finally, the duration of residential care remains consistent with community practice standards. Considering the patients clinical presentation and the peer-reviewed literature, residential placement was a safe, appropriate disposition consistent with good medical practice. Accordingly, residential mental health and substance abuse treatment services were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 55-year-old male has requested coverage for a past sodium fluoride (NaF-18) positron emission tomography scan performed for evaluation of his prostate cancer.  Findings:  Three physician reviewers found that the patient has prostate cancer (stage T3B, N1, M0).  On the date at issue, a nuclear medicine bone scan showed no evidence of bone metastases.  Per the submitted documentation, PET/CT scan performed subsequently confirmed nodal involvement.  The patients case was presented to a Tumor Board, and a sodium fluoride (NaF-18) positron emission tomography scan was recommended.  This diagnostic procedure was performed.  In this clinical setting, the sodium fluoride (NaF-18) positron emission tomography scan performed was likely to have been of greater benefit than other tools for evaluating this patient.  The diagnostic procedure at issue is more sensitive than conventional bone scans.  The results of the sodium fluoride (NaF-18) positron emission tomography were needed for treatment planning in this patients case.  The current medical evidence supports the superior efficacy of the diagnostic procedure at issue in this clinical situation.
Appeal type: Experimental/Investigational
Decision: Overturned

Findings:  The physician reviewer found that An enrollee has requested authorization and coverage for next generation sequencing (NGS) and comprehensive genetic testing. Per the National Comprehensive Cancer Network (NCCN) guidelines, molecular diagnostic studies, such as next generation sequencing (NGS), is considered the standard of care for the evaluation of patients with non-small cell lung cancer (NSCLC). As noted in the medical literature, numerous gene alterations have been identified that impact therapy selection (Jordan, et al.; Robson, et al.). The NCCN strongly recommends broader molecular profiling with the goal of identifying rare driver mutations for which effective therapies may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. As noted in the medical literature, testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with Tempus is appropriate for this patient, who presents with a history of metastatic NSCLC. Previous testing with Tempus and Guardant360 do not obviate the need for additional NGS testing. Therefore, the requested NGS testing and comprehensive genetic testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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.