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

A 48-year-old female enrollee has requested for BRCA 1 and 2 genetic testing for evaluation of her medical condition. Findings:  The physician reviewer found that there are a variety of guidelines published in an effort to make a determination as to whether there is a reasonable enough probability of finding a mutation to justify the analysis. This patient is not from Ashkenazi Jewish descent (a high-risk group). Secondly, she does not have a family history suggestive of BRCA positivity. The only indication for testing in her case is the fact that she has a history of right breast cancer, diagnosed at age 47. A variety of guidelines have been developed for this situation. National guidelines (see National Comprehensive Cancer Network guidelines) indicate that BRCA testing should be performed: if the patient was diagnosed with breast cancer when less than 45 years of age; if the patient was diagnosed under the age of 50 when there is at least one close relative who was diagnosed with breast cancer under the age of 50, or one relative diagnosed with ovarian cancer. This patient does not fulfill these criteria. Based on the evidence provided, the patients risk of being BRCA positive is less than 10% and she does not meet accepted indications for BRCA 1 and 2 testing.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollees abnormal glucose.Findings: All three physician reviewers found despite some providers advocating for use of the advanced lipoprotein analysis, the American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, their guidelines recommend use of standard risk factors and lipid profiling to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. These guidelines are formulated based on thorough review of current literature. All told, the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the testing at issue was 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: All three physician reviewers 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Privigen intravenous immunoglobulin (IVIG) infusions (1 gm/kg monthly for three months). The records provided for review document that this patient presents with symptoms concerning for long COVID-19. The patients provider has recommended treatment with Privigen IVIG. However, there is a lack of data in the peer-reviewed medical literature to support treatment with IVIG for this patient. Vinkenoog and colleagues reported on a retrospective observational study in which IgG antibody was evaluated as a correlate to COVID-19 symptoms. The authors did not directly assess the safety and efficacy of IVIG for the treatment of patients with neurologic symptoms as a result of COVID-19 infection and their findings do not include a recommendation for treatment with IVIG. Toscano and colleagues found that IVIG provided some clinical improvement in patients presenting with Guillain-Barre syndrome after COVID-19 infection. However, there is a lack of support for treatment of IVIG for this patients long COVID-related neurologic symptoms such as anxiety, palpitations, and joint pain post infection. For these reasons, the requested Privigen IVIG infusions (1 gm/kg monthly for three months) are not medically necessary for treatment of this patient. 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 allergy and immunology 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 38-year-old female enrollee has requested Verifi prenatal laboratory testing (CPT code 84999) for evaluation of her  pregnancy.  Findings:  Two physician reviewers found that current methods of fetal genetic testing involve obtaining samples of amniotic fluid, placenta, or fetal blood. The invasive techniques required for obtaining fetal samples place the fetus at risk of injury. Noninvasive prenatal testing that uses cell free fetal DNA from the plasma of pregnant women, including the Verifi prenatal test, offer potential as a screening tool for fetal aneuploidy. The American College of Obstetricians and Gynecologists (ACOG) recommend testing for aneuploidy either by screening or invasive prenatal diagnosis regardless of maternal age. Cell free fetal DNA is one option that can be used as a preliminary screening test in women at increased risk of aneuploidy, including patients who are ages 35 and older. Since the Verifi prenatal test is a type of non-invasive cell free fetal DNA test, and the patient was over 35 years of age, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee has requested tinnitus retraining therapy (TRT), including applicable durable medical equipment for treatment of his tinnitus.  Findings:  Two physician reviewers found that there was no history of excessive noise exposure.  Information pertaining to other therapies was not provided.  Physical examination was unremarkable, and MRI of the brain was normal.  The tinnitus was determined to be of uncertain etiology, and tinnitus retraining therapy was recommended.  Studies to date are inconclusive regarding the benefit of tinnitus retraining therapy for the treatment of tinnitus.  Further studies are needed at this time. Over half of their patients could not tolerate the tinnitus control instrument or obtained a poor result from the tinnitus retraining trial (Hatanaka and colleagues). At this time, there is a lack of scientific evidence establishing the superior efficacy of the requested tinnitus retraining therapy in this clinical scenario. I have determined that the requested therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for seven treatments with Sclerosing injections. Findings:  The physician reviewer found that There is long-established research that supports that alcohol sclerosing injections are a viable option in the treatment of intermetatarsal neuroma. Hughes and colleagues conducted a clinical trial in which 101 patients with Mortons neuroma received an average of 4.1 treatments of sonographically guided alcohol injections into the lesion. Partial or total symptom improvement was reported by 94% of the patients. They concluded that alcohol injection of Morton's neuroma has a high success rate and is well tolerated. These statistics are comparable to more established local cortisone injection treatments. While surgical excision of neuromas has long been thought to be more definitive, a retrospective review performed by Kasparek and Schneider found that following surgical treatment of Mortons neuroma, patients reported surprisingly low success rates with 44.9% of patients reporting excellent results and 31.6% of patients reporting good results. The evidence supports that alcohol sclerosing injections for intermetatarsal neuromas are significantly beneficial and a viable alternative that may be preferable to surgery. In this case, sclerosing injections were supported by research and they constituted a conservative treatment option that allowed the patient to avoid the disability and increased risk of complications that comes with surgery. The patient also reported significant relief from this treatment. Under these circumstances, the Sclerosing injections at issue (CPT-64632) were likely to be more beneficial than any other available standard treatments for the patients medical condition.Findings: Two out of three physician reviewers found that the Sclerosing injections at issue (CPT-64632) were likely to be more beneficial than any other available standard treatments for the patients medical condition.Credentials/Qualifications: Physician reviewer 1 is board certified in foot surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in foot and ankle surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and are 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 39-year-old female enrollee has requested prosthetic leg components (identified by HCPCS codes L5653, L5665, L5920 and L5950) for the treatment of her medical condition. Findings:  The physician reviewer found that HCPCS code L5653 is for an addition to lower extremity, knee disarticulation, expandable wall socket. The patient is an above the knee amputee. There is no evidence in the submitted clinical records demonstrating that this component was necessary to improve function or mobility in this particular patient. Therefore, the medical necessity of this component is not established. HCPCS code L5665 is for an addition to lower extremity, socket insert, multidurometer, below knee. Again, this patient is an above the knee amputee. The submitted clinical records do not demonstrate that this particular component would result in functional benefit for this patient. Therefore, this component was not medically necessary. HCPCS code L5920 is for an addition, endoskeletal system, above knee or hip disarticulation, alignable system. The Health Plan notes that alignable componentry was previously allowed at the time the new prosthesis was billed and the componentry was reused. Given this, the submitted documentation does not support additional billing for alignable componentry. Therefore, this component was not medically necessary. HCPCS code L5950 is for an addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber, or equal). The Health Plan indicates ultra-lite material for componentry was allowed at the time the new prosthesis was delivered. There is no evidence in the clinical records to support the subsequent use of ultra-lite material in this setting. Therefore, this component was not medically necessary.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for 20 hours per week of intensive behavior health treatment, four hours per week of supervision and four hours per week of parent training for treatment of the autism.Findings:  The physician reviewer found that The behavior therapy at issue is Developmental, Individual Difference, Relationship-Based Model of Intervention (DIR) appears to have some emerging data to support its use. Although, there may be some benefit from DIR based therapy, there is a lack of evidence in the medical literature to support is use in this clinical setting. The medical literature supports an ABA approach as effective for treatment of this patients condition. Moreover, there is sufficient medical literature supporting ABA therapy as an effective treatment for individuals with autism. Given the lack of sufficient support in the peer-reviewed literature, the request for 20 hours per week of intensive behavior health treatment, four hours per week of supervision and four hours per week of parent training are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 an enrollee has requested authorization and coverage for future cancer treatments at a medical center with an on-site PICU. American Academy of Pediatrics (AAP) Standards for Pediatric Cancer Centers state that initial diagnostic assessment, induction therapy, and management of complications or recurrences should be provided in a pediatric center that has facilities with an immediately accessible and fully staffed, on-site PICU. The patient has a diagnosis of pre-B cell acute lymphoblastic leukemia, and had a near fatal episode during her induction chemotherapy. The patient developed neutropenic fever and septic shock and was admitted to an in-plan facility. With impending shock, a transfer was initiated. That same day, the patient had two bradycardic arrests requiring cardiopulmonary resuscitation. Fortunately, there was return of circulation, but the transfer itself could have been obviated if the patients initial admission had been at a medical center with an on-site PICU. Given the patients diagnosis and care needs, AAP Standards indicate that the patients future cancer treatments should be provided in a pediatric center that has facilities with an immediately accessible and fully staffed, on-site PICU. Accordingly, it is medically necessary for the patient to receive future cancer treatments at a medical center with an on-site PICU.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certifications in hematology and medical oncology, 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 37-year-old male enrollee has requested for Tramadol and Diovan for treatment of his diabetic neuropathy. Findings:  The physician reviewer found that Diovan is not medically necessary for this patient. The treatment of painful diabetic neuropathy may require opioid medications.The reasons for this discontinuity of care are not known. The patient should return to the neurologist as soon as possible to complete his evaluation and the course of action originally recommended to wean the patient off Tramadol.
Appeal type: Medical Necessity
Decision: Overturned

A 23-year-old male enrollee has requested for gastric bypass surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that with a BMI of 44.4, this patient meets all generally accepted criteria for bariatric surgery. He is morbidly obese, has failed dietary efforts and completed a thorough multidisciplinary evaluation without evidence of dietary, medical, metabolic or behavioral barriers to surgery. There is no medical literature to support pre-surgical mandated weight loss of any specified length of time if a patient has otherwise failed reasonable weight loss attempts. Further attempts at non-surgical weight loss are not likely to be effective for this patient. He is an appropriate candidate for weight loss surgery and is likely to benefit from the procedure.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested authorization and coverage of the medication lamisil for the treatment of onychomycosis.  The Health Plan denied the enrollees request indicating that the requested treatment is not medically necessary.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer overturned the health plans denial on the basis that the requested medication is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sonablate high intensity focused ultrasound (HIFU) (CPT 55880). Findings:  The physician reviewer found that patients records document a history of elevated prostate specific antigen (PSA) and Gleason 4+3 prostate cancer. The patients provider has recommended treatment with HIFU to address only the diseased portion of the prostate gland. However, HIFU for multifocal prostate cancer is not supported by adequate evidence as compared to radiation or prostatectomy to support its use in this patients clinical setting. Ahdoot and colleagues found that, Prostate cancer focal therapy is an attractive option for well-selected patients because of its low complication profile; however, long-term oncologic outcome is still lacking, and early recurrence rates are high, limiting the ability of most urologic associations from endorsing its routine use. All told, the requested Sonablate HIFU (CPT 55880) is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested services 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 urology 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 61-year-old female enrollee has requested intraperitoneal nutrition for treatment of her end stage renal disease. Findings:  The physician reviewer found that in this patients condition, alternative treatment modalities should be explored while she is being continued on IPN therapy for the next six months. The primary goal is for small solute clearance and dietary protein supplementation to be optimized within six months as options for possible transplantation, and consideration given to hemodialysis if the patients serum albumin cannot be normalized, are explored. A repeat peritoneal equilibrium test (PET) should be done to assess high average transport rate (D/P creatinine), and if confirmed, treatment should be changed to 4-hour dwell CAPD mode with manual 2-2.5 Liter exchanges 3 times daily, and 2 exchanges at night with the cycler (high dose PD). Ideally, the correct IPN prescription should be determined within two months, then allowing an additional two months for the patients serum albumin level to stabilize. The patient should continue dietary protein augmentation beyond discontinuation of IPN to maintain and improve serum albumin. Over the ensuing months, the patient should be observed with nPNA to determine whether dietary protein supplementation alone is sufficient to sustain serum albumin levels less than 3.5 g/dL with enhanced small solute clearance on peritoneal dialysis. If the patients serum albumin level cannot be sustained and renal transplantation is not an option, the patient may be considered for hemodialysis at the end of six months of IPN therapy.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested anesthesia services provided during an endoscopy for treatment of her history of allergy/intolerance to multiple medications.  Findings:  The physician reviewer found that based on review of the available records, anesthesia services were medically necessary for the patients endoscopy performed on said date. The enrollee presented with a history significant for sleep apnea, a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing during sleep. Sleep apnea is particularly accentuated during medication-induced sedation. Anesthesia services are highly recommended for sleep apnea due to risk of airway obstruction. Hausman and Reich stated that not all procedures are well suited for the office with sedation. Unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. The providers notes indicated that the endoscopy procedure would be of long duration and given the patients risk of airway obstruction as a result of her history of sleep apnea, anesthesia services were appropriate. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in endoscopy or colonoscopy. The authors concluded that moderate sedation provides a high level of provider and patient satisfaction as well as low risk of serious adverse events with all currently available agents. Given this patients history of sleep apnea, even mild agents such as benzodiazepines and narcotics may increase the risk of airway obstruction and require the services of an anesthesiologist. All told, the anesthesia services provided on the date in question were therefore medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 61-year-old male enrollee has requested for liposuction excision for treatment of his lipoma. Findings:  The physician reviewer found that the medical necessity for liposuction excision of the lipoma is not established. The records do not document a concern over malignancy or any functional problems related to the lipoma. The patient indicates in his appeal letter that the lipoma was painful, but the records do not include any preoperative physician documentation indicating the lipoma was symptomatic. Although liposuction is an effective method for removal of lipomas, the medical records do not document any health-related problems secondary to this lipoma.
Appeal type: Medical Necessity
Decision: Upheld

A forty-seven year-old male who presents with memory loss and loss of smell is requesting authorization for a PET scan.Reviewers Findings:  The reviewing physician found that there is not currently sufficient medical evidence to support the application of PET imaging for patients such as this one.  The reviewing physician found that the Health Plan denial should be upheld.