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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Inspire upper airway stimulation system. In a meta-analysis of five retrospective studies on the outcomes of patients with hypoglossal nerve stimulator implantation versus patients undergoing surgical interventions, including uvulopalatopharyngoplasty, expansion sphincter pharyngoplasty, transoral robotic surgery (lingual tonsillectomy and tongue reduction), and other upper airway surgery, Neruntarat and colleagues concluded that upper airway stimulation provided improved objective and similar subjective outcomes compared to other upper airway surgical procedures. Given the evidence in current medical literature supporting the use of hypoglossal nerve stimulators, in this clinical setting, the requested service is likely to be more beneficial in managing the patients obstructive sleep apnea (OSA) that is refractory to continuous positive airway pressure (CPAP) therapy. Therefore, the Inspire upper airway stimulation system is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested Inspire upper airway stimulation system is 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 service 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 and 3 are board certified in otolaryngology and are actively practicing. Physician reviewer 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Otezla 30 mg, twice a day. Findings: The U.S. Food and Drug Administration (FDA) approves the use of apremilast (brand name Otezla) for the treatment of moderate-to-severe plaque psoriasis. A study reports that apremilast, given orally at 20 or 30 mg twice daily, seems to be efficacious, safe, and tolerable for patients with moderate-to-severe plaque psoriasis. In this case, the records note that the patient has widespread disease and has failed several topical agents and ultraviolet therapy. Given that the patient is a good candidate for systemic therapy, and as current medical literature supports the use of apremilast in this clinical setting, the requested medication is medically indicated. Therefore, Otezla 30 mg, twice a day, is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology 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 39-year-old male enrollee has requested coverage for the prescription medication Lyrica for treatment of his testicular pain. Findings:  The physician reviewer found that the patient had an acute onset of exquisite testicular tenderness. The clinical picture and the quality of the pain do not suggest neuropathic pain, but are more likely a primary inflammatory condition. The patient was not tried on the usual pain management therapies for either somatic pain or neuropathic pain such as gabapentin or tricyclic antidepressants. While Lyrica may have provided some pain relief, it was used as a first-line agent when many other alternatives were available. This is not consistent with the standard of care within the neurological community.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the abdomen. This patients records document current complaints of epigastric and right upper quadrant pain without findings to explain symptoms on ultrasound. The patient previously underwent cholecystectomy in 2004. The patients provider has recommended further evaluation with MRI of the abdomen. Researchers supports the use of MRI with magnetic resonance cholangiopancreatography for the evaluation of patients with right upper quadrant pain, lack of fever and leukocytosis, possible biliary disease, and negative or equivocal ultrasound. Right upper quadrant abdominal pain can be indicative of choledocholithiasis or other biliary disease such as choledochal cyst, or uncommon complications such as cholecystitis of the remnant gallbladder after cholecystectomy. In this clinical setting, the requested MRI of the abdomen is consistent with the ACR recommendations. For these reasons, the MRI of the abdomen is medically necessary for evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with subspecialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 14-year-old male has requested growth hormone (GH) therapy with Humatrope for treatment of growth failure.  Findings:  The physician reviewer found that a recent study of 35 children with achondroplasia who were treated with GH therapy for up to five years found that linear growth improved without significant side effects. This study confirmed previous studies involving achondroplastic children, which reported positive growth effects from GH therapy. In this instance, the patients growth has been severely impaired despite bone lengthening surgery. A one-year trial of GH therapy is clinically indicated.
Appeal type: Experimental/Investigational
Decision: Upheld

A 61-year-old male enrollee has requested real-time cardiac monitoring for evaluation of his atrial fibrillation.  Findings:  Two physician reviewers found that this patient had recurrent symptomatic atrial dysrhythmias treated with two prior ablation procedures. In this circumstance, serial continuous 24 to 48 hour Holter monitoring should be able to effectively identify dysrhythmias during recurrent intermittent symptoms of palpitations.  Likewise, self-activated non-real-time and non-continuous monitoring devices (event recorders) should be effective at recording dysrhythmias during less frequent symptoms.  In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient.  There is no documentation to indicate the patient is not able to effectively manage these standard monitoring devices and no indication that these have been previously obtained to evaluate the patients symptoms.  Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient-activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias.  Thus, real-time cardiac monitoring was not likely to have been the most beneficial method of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee requested Zomig Spray for medical treatment of her refractory migraine with aura.  Findings:  The physician reviewer found that Zomig has been demonstrated to be effective for the treatment of migraine. Zomig Spray has onset of action as soon as 10 minutes, and is parenteral, so is effective when patients have nausea and vomiting and are unable to take an oral medication. As this patient has severe migraines with nausea and vomiting, she requires a parenteral route of administration for her migraine medication. This patient has tried numerous triptans with inadequate response, but has reported satisfactory results with Zomig Spray. Thus, the requested Zomig Spray is medically necessary for treatment of this patients migraines.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine and neurology 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

A 50-year-old female enrollee has requested computed tomography (CT) scan (whole body CT without contrast) for evaluation of the enrollees autoimmune polyneuropathy.  Findings:  Two physician reviewers found that the patient presents with hearing loss, malaise/weakness, sinus congestion, dizziness, and fever, as well as diagnosis of Reynauds phenomenon. An autoimmune polyneuropathy and chronic pancreatitis have also been diagnosed. The records indicate the patient has a Perm Cath for plasma exchange and intravenous immunoglobulin (IVIG). The patient has requested authorization and coverage for computed tomography (CT) scan (whole body CT without contrast), which the Health Plan has denied as investigational. The peer-reviewed medical literature fails to support an indication for the requested whole body CT scan in this patients case. The patients concern for calcium deposits does not require further evaluation with imaging at this time. All told, the requested whole body CT without contrast is not likely to be more beneficial for evaluation of this patients medical condition than standard interventions.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic test for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the patient is diagnosed with invasive ductal carcinoma of the breast.  The records also indicate that the patient has a family history of cancer in her mother, maternal grandmother and a maternal aunt. On her paternal side, her grandfather had gastric cancer and her grandmother had colon cancer. The patient consulted with a genetic counselor who requested genetic testing of the patient. The Health Plan denied genetic test as investigational for evaluation of this patient. The National Comprehensive Cancer Network and the U.S. Preventative Task recommend testing of women for BRCA mutations in certain clinical settings. In this case, BRCA testing was appropriate and of clinical benefit to the patient. This patient is under the age of 50 and diagnosed with breast cancer. The patient also has two relatives with breast cancer. Under the recommended guidelines, the genetic test for the BRCA mutations was appropriate. However, genetic test (CPT code 81479) includes panels of other gene mutations. Although many of the other genetic mutations are of real interest and are being studied, for the most part, these tests have not been found to be significant. Such broad testing is not included in the guidelines by the major organizations. American Society of Clinical Oncology recommends the use of genetic tests that are of clinical utility. The records indicate that the Health Plan had approved BRCA testing for this patient. Therefore, in light of current medical literature and guidelines, the genetic test with CPT code 81749 was not likely to be more beneficial for evaluation of this patient than any available standard testing of this patients medical condition.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: 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for Foundation One gene testing for evaluation of the enrollees endometrial cancer. Findings:  The physician reviewer found that Foundation One assay explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific target which could inform the clinician as to what chemotherapeutic agent would be useful. Thus far, however, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have offered convincing evidence of the efficacy of this approach. A randomized trial by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular assay versus by the oncologists clinical judgment. All told, Foundation One gene testing provided on 8/16/16 was not likely to more effective than other methods of evaluating this patient. Final Result: Two of three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in 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

Nature of Statutory Criteria/ Case Summary: The enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services.  Findings:  The physician reviewer found that the enrollee has a history of depression, psychosis, substance use, including cannabis and prescription amphetamines. He was actively abusing marijuana and prescription amphetamines. He transitioned from PHP to an intensive outpatient program (IOP). Notes indicated no current suicidal ideation. He denied a history of ever acting on suicidal ideation. Psychiatry notes indicated improvement in mood, good energy, feels rested, normal speech, no suicidal/homicidal ideation, no auditory verbal hallucinations, started gaining insight into connection between substance use, psychosis and social isolation. Individual therapy indicates the enrollee expressed insight into understanding on how structure, abstinence and medications can improve his lifestyle. Improvement in his mood and sleep was noted and he denied suicidal ideation and cravings. Review of the record indicates the enrollees symptoms could have been managed at a lower level of care than the intensive outpatient (IOP) level. The enrollees composite score of 14 correlates with Level II: Low Intensity Community Based Services.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 47-year-old female enrollee has requested for Botox injections for treatment of her migraine headaches.  Findings:  Three physician reviewers found that Botox is not a first-line therapy for migraine headaches. Although there is some literature to support its use in some patients with refractory chronic headaches or migraines (see above literature) it should not be used in place of more standard and proven therapies.  This patient does not have a history that suggests that she has had completely refractory headaches. The patients neurologist states that the patient had a recurrence of headaches after attempting a taper of Nortriptyline (without mentioning any side effects on this medication), suggesting that the management was acceptable before that time.  Furthermore, the patient is also reported to have had a partial response to a relatively low Neurontin dose. For these reasons, Botox does not appear to be the optimal headache therapy for this patient. If the patient fails an extended trial of Neurontin and Lyrica, then the appropriateness of Botox can be reevaluated at that time.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Prometheus Anser ADA testing. There is insufficient medical evidence to support the effectiveness of Prometheus Anser ADA testing compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies. It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control.  Additionally, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management.  For these reasons, Prometheus Anser ADA testing was not likely to have been of greater benefit than other methods of evaluating this patient. Findings:  Three physician reviewers found 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.Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: A enrollee has requested authorization and coverage for silver ring splints. Findings:  The physician reviewer found that Ehlers-Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic widespread pains and poor health-related quality of life. A generalized hyperalgesia has been reported, possibly due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia. Treatment approaches with the highest rated subjective benefits in pain relief in survey literature have included opioids, splints, massage and heat, but the effectiveness of treatment is generally reported to be poor and evidence-based recommendations are largely lacking. Moreover, the requested proposed silver ring splints have not been demonstrated to be more effective than standard plastic finger splints. The plastic splints can be adjusted for proper fit, which was done in this patients case. In addition, the provider documented that the patient had excellent mediation of pain with the plastic splints. Thus, the requested silver ring splints are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be equipment. 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: Upheld

A 64-year-old female enrollee requested bilateral breast magnetic resonance imaging (MRI) for medical evaluation of the enrollees dense breasts.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested diagnostic procedure.  This patient has a family history of breast cancer with at least one first-degree relative with the disease.  Her breast tissue is heterogeneously dense on mammography.  However, the current medical evidence does not support the requested diagnostic procedure in this clinical setting.  While MRI is the most sensitive means with which to detect early breast cancer, this technique is medically necessary when there is a greater than 20% lifetime risk of breast cancer or when there is BRCA genetic mutation.  Per the submitted records, this patient has not completed a Gail risk assessment and does not have known BRCA mutation, as genetic testing does not appear to have been performed.  All told, the requested bilateral breast MRI is not medically indicated for the evaluation of this patient.