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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested DecisionDx Melanoma Assay testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Uveal melanomas are rare, and up to 50% are at risk for metastases. Among the most important risk factors are chromosomal markers in the tumor identified by use of the Decision DX Melanoma Assay test.  Using samples of primary uveal melanomas obtained by fine needle biopsy, tumors are classified as having low or high metastatic potential, depending on the expression of 15 genes.  DecisionDx Melanoma Assay testing is a standard of care for determining prognosis and need for more aggressive therapy and is superior to other testing available.  Therefore, DecisionDx Melanoma Assay testing was likely to have been of greater benefit than other tools for evaluating this patient.  Final Result: Three 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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

The parent of a 12-year-old female enrollee has requested past and future coverage for the combination of the CLEAR protocol and Schroth method for treatment of her idiopathic scoliosis.  Findings:  Three physician reviewers found that the patient has and is being treated with a combination of the CLEAR protocol and Schroth method for idiopathic scoliosis. Previously, the clinical records document prescription of a hard brace prescribed by an orthopedist. The patients spinal curves were noted to have increased with use of the hard brace as the thoracic curve was initially 32 and increased to 50, and lumbar spine was initially 37 and increased to 45 with hard bracing. The patients initial measurement of the thoracic spine was 32 and lumbar spine was 37. Upright magnetic resonance imaging (MRI) after hard bracing, included the thoracic spine at 50 and lumbar spine at 45. Magnetic resonance imaging (MRI) of the cervical spine showed unilateral ectopic cerebellar tonsils/Chiari type I malformation. Description of treatment recommended by the providers includes the use of a motorized scoliosis traction table, dropped traction vibrating traction and spinal manipulative therapy including occiput to C1 flexion manipulation, as well as a series of Schroth exercises, cervical spinal molding, Thera-Band pull down side sitting, and downward dog with belt and chair. The presence of Chiari malformation with syringomyelia is a recognized neurogenic cause for progressive scoliosis resistant to conservative treatment. This patient does not have syringomyelia but does have a documented Chiari type I malformation. The lack of maintenance of curve in a scoliosis brace prescribed by an orthopedic surgeon suggests a neurological basis for her scoliosis. In the absence of a neurological examination and a follow-up review with an orthopedic surgeon, there is a possibility that this patients scoliosis is not idiopathic but neurogenic and related to the diagnosed Chiari type I changes with a posterior column neurological disorder. The proposed complimentary alternative treatment includes cervical spine manipulation, which may be contraindicated in this patient. It is therefore not in the best interest of this patient with documented Chiari malformation to undergo the chiropractic program described consisting of a combination of the CLEAR protocol and Schroth method.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A 75-year-old female enrollee has requested authorization and coverage for 100 days of physical therapy and occupational therapy. Findings:  The physician reviewer found that This patient sustained a stroke over four months ago and remains in need of 24-hour care. She has made modest improvements in bed transfers during her recent SNF admission. Given her progress thus far, the patient may benefit from an additional five days of physical therapy and occupational therapy. However, the documentation does not support the requested 100 days of additional physical and occupational therapies. The patient required total assistance for bathing and toileting, and maximum to total assistance for transfers. She required moderate assistance for bed transfers, and maximum to total assistance for other transfers. She required maximum to total assistance for toileting and dressing. Given this limited progress, five additional days of physical therapy and occupational therapy are medically necessary. Final Result: The reviewer determined that a portion 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 physical medicine and rehabilitation with subspecialty certification in neuromuscular 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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a cranial orthotic device (molding helmet, DOC band) for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies.  Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible.  The American Academy of Pediatrics published prevention and management guidelines for positional skull deformities in infants.  The authors noted skull molding helmets are an option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes. Surgery is rarely necessary but may be indicated in severe refractory cases of deformational plagiocephaly or in patients with craniosynostosis.  In this patients case, the records document abnormal head shape with brachycephaly compounded by plagiocephaly. Anthropometric measurements indicate severe brachycephaly and plagiocephaly is less pronounced.  Based on measurements, recommendations in the literature, and standard of care, a cranial remolding orthosis is medically necessary.  All told, the requested cranial orthotic device (molding helmet, DOC band) is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested device 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 pediatrics with sub-specialty certification in pediatric critical care 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: Upheld

An enrollee has requested reimbursement for Botox injections for treatment of the enrollees medical condition. Findings:  The physician reviewers found that there is a lack of evidence based literature to demonstrate the superiority of Botox injections over available standard therapy for treatment of Oddi dysfunction (SOD), type III. The use of Botox injections to address SOD was initially utilized to provide short-term relief of symptoms. However, a prospective randomized blinded sham by controlled one year outcome study showed no correlation between manometric findings and the outcome after sphincterotomy. Moreover, the patients receiving sham therapy had a statistically significantly better outcome than those undergoing biliary or dual sphincterotomy. In this patients case, there was no manometric documentation provided to support a diagnosis of SOD. While Botox has been used on a case by case basis for a host of gastrointestinal disorders, there is a lack of support for its use for the treatment of this patient. The patient derives transient subjective benefit from her Botox administrations but the objective support for this approach is lacking. Final Result: Two of three reviewers determined that the services at issue were 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 40-year-old male enrollee requested Mepron 750mg/5ml oral suspension for medical treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The diagnosis of Babesia duncani appears to be based on a single serology.  Specifically, Babesia duncani (WA-1) IFA IgG was reported to be 1:256.  A normal value is less than 1:256.  This is not a significant result absent repeat testing or other clinical information that would suggest Babesia duncani infection was present.  Per the current medical evidence, patients with non-specific symptoms, such as this patient, are not likely to have infection with Babesia.  There is a lack of support for the requested medication in this clinical setting.  All told, Mepron 750mg/5ml oral suspension is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:Anenrollee has requested reimbursement for the prostate cancer antigen (PCA3) gene test.  Findings:  The physician reviewers found that The patientwho had an elevated prostate-specific antigen (PSA). The records noted that he underwent a biopsy of the prostate. He developed sepsis and required hospitalization. The patient did not want to have another biopsy performed.  The provider decided to do a prostate cancer antigen (PCA3) gene test instead of a biopsy.  The test returns with a value of 42.4. The patient has requested reimbursement for the PCA3 gene test performed The Health Plan denied reimbursement stating that PCA3 gene test was investigational for the evaluation of this patients medical condition. According to the medical literature, the indications for using PCA3 in diagnosing prostate cancer are not clear.  While this test has been used as an alternative to repeat biopsies of the prostate, its continued use to determine if a patient has cancer has come under scrutiny. The medical evidence is unclear as to its efficacy in detecting cancer in the prostate. In this patients case, the value of 42.4 on the test was suspicious for cancer. The value of the PCA3 reinforced the need for another biopsy.  While it is understandable that this patient would fear the same complications with another biopsy, there were precautions available to him.  In sum, this test had little value in determining whether he had cancer. Therefore, the PCA3 gene test performed  was not likely to have been more efficacious than the available standard modalities for the evaluation of this patients medical condition.Final Result: The reviewers determined that the services at issue were 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: All 3 Physician reviewers are board certified in urology and is actively practicing. The reviewers are an 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 parent of a 10-year-old male enrollee requested magnetic resonance spectroscopy (MRS) (CPT 76390) for medical evaluation of the enrollees optic glioma of the brain.  Findings:  The physician reviewer found that the requested magnetic resonance spectroscopy is not medically necessary for evaluation of this patients optic glioma of the brain. Magnetic resonance spectroscopy can be useful to determine whether a mass is a brain tumor or to distinguish viable tumor from radiation necrosis. However, this patient has not been treated with radiation. Further, there is a lack of evidence that magnetic resonance spectroscopy has a role in assessing a patients response to therapy (Chronaiou, et al; Rossi, et al). Moreover, there is no indication that a magnetic resonance spectroscopy would have any impact on this patients treatment. All told, the requested magnetic resonance spectroscopy is not supported as medically necessary for evaluation of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old female enrollee has requested for Rituxan for treatment of her multiple sclerosis. Findings:  Three physician reviewers found that rituxan is an unproven drug for the treatment of PPMS. At this time, there are no reported clinical studies of Rituxan and PPMS. Nor is there any evidence that Rituxan is effective for the treatment of PPMS. Although there is an ongoing study of Rituxan in this setting, no information regarding the drugs efficacy is yet available.
Appeal type: Medical Necessity
Decision: Upheld

A 44-year-old female enrollee has requested lumbar spinal fusion surgery for treatment of her low back pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested procedure.  The role of fusion in the management of lumbar spinal disorders is generally accepted in cases of instability associated with trauma, tumor, or infection, or in cases of spondylolisthesis or iatrogenic instability.  In most patients with low back pain, symptoms resolve without surgical intervention.  The use of discography remains controversial because of the presence of false-positive findings.  For patients with back pain and degenerative changes, fusion is no more effective than intensive rehabilitation. Improvement following fusion can be expected in patients with an established indication, but patients with chronic low back pain experience less improvement.  Low back pain without a pathomorphological correlation or explainable functional deficit is not an indication for fusion.  In this patients case, there is a paucity of documentation to support the presence of instability or other indication for surgery.  The discography, unsupported by other findings, is insufficient as an indication.  All told, the requested lumbar spinal fusion surgery is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Celebrex 200 mg for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. According to the U.S. Food and Drug Administration (FDA), Health care professionals and patients can be assured that these FDA-approved generic drugs have met our rigorous approval standards. The FDA further states, Generic prescription drugs approved by the FDA have the same high quality and strength as brand-name drugs. Generic drug manufacturing and packaging sites must pass the same quality standards as those of brand-name drugs. Therefore, the FDA approved generic medications are manufactured to be chemically similar to the brand name mediations and the side effects are the same.  As such, the request for name brand Celebrex 200 mg has not been established as medically necessary for treatment of the patients medical condition.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 internal medicine with sub-specialty certification in rheumatology 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 reimbursement for the genitofemoral nerve blocks for treatment of the enrollees groin pain. Findings:  Two physician reviewer found that this patient has neuropathy related to inguinal hernia repair. The genitofemoral nerve innervates the skin which is in the crease between the thigh and lower abdomen. Inguinal hernia repair may cause a lesion to the nerves in this area, with or without graft placement.  In terms of performing anesthesia, these blocks are used during procedures of the groin and lower abdomen at times. Per the medical literature, there is evidence that these blocks can be used to diagnosis pain to that location. However, in terms of pain management, there is a lack of large, retrospective, double-blind studies that show documented benefit.  Therefore, the medical literature supports the initial diagnostic block. However, there is a lack of support for the second therapeutic injection.  In sum, The first treatment with a genitofemoral nerve block was likely to have been more effective than other available modalities. The medical evidence has not established the superior efficacy of a follow-up genitofemoral nerve block. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested bilateral magnetic resonance imaging (MRI) of the knees for evaluation of his knee pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested bilateral MRI of the knees in this clinical setting.  Per the submitted documentation, the patient has not been seen by an orthopedist in a significant amount of time.   A recent evaluation by an orthopedist is necessary to establish the medical necessity of the requested services.  All told, the requested bilateral MRI of the knees is not medically indicated 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment of all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The initiation of treatment will help avoid further progression of fibrosis.  All told, Sovaldi for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her exam been done using the two-dimensional technique alone.  Final Result: Two 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:  All three reviewers are board certified 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.