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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation (CPT code 64566) and prospective authorization and coverage for percutaneous tibial nerve stimulation (CPT code 64566) for seven weeks in order to complete the initial 12-week treatment plan and then every three to four weeks for maintenance.Findings:  Two of the three physician reviewers found that the current medical evidence has not established the superior efficacy of the services at issue in this setting. There is a lack of reliable data regarding maintenance percutaneous tibial nerve stimulation. Percutaneous tibial nerve stimulation is considered a third-line therapy in this clinical setting, and this modality has not been demonstrated to be more effective than anticholinergic or antimuscarinic therapy. There are alternatives which are safe for this patient. Therefore, percutaneous tibial nerve stimulation (CPT code 64566) was not likely to have been of greater benefit than other treatment options. Additionally, the superior effectiveness of future percutaneous tibial nerve stimulation (CPT code 64566) for seven weeks in order to complete the initial 12-week treatment plan and then every three to four weeks for maintenance has not been demonstrated. Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old female enrollee has requested for Tysabri for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the FDA has approved Tysabri as monotherapy for the treatment of patients with relapsing forms of multiple sclerosis to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations. It is generally recommended for patients who have had an inadequate response to, or are unable to tolerate, alternate multiple sclerosis therapies.
Appeal type: Medical Necessity
Decision: Overturned

A 48-year-old male enrollee has requested authorization and coverage for chemical ablation of the right leg for treatment of the enrollees right leg varicose veins. Findings:  The physician reviewer found that Accessory varicose veins measuring less than 4mm are ideally treated with injection sclerotherapy. This is defined as medically necessary when the following criteria are met: reflux at saphenofemoral junction (SFJ) or saphenopopliteal junction (SPJ) with treatment, as an adjunctive treatment on the same date of service or if within 12 months of prior procedure with persistent varicosities. This patient does meet the above mentioned criteria for sclerotherapy. There are two well defined CPT codes for sclerotherapy (36470 and 364671). If ultrasound is used, then 76942-26 can be added. However, there is no indication to use an unlisted procedure code for this chemical ablation technique, which is nothing more than sclerotherapy with ultrasound imaging. Thus, the procedure indications were correct but the coding of the procedure is erroneous. As such, the requested chemical ablation of the right leg is medically necessary but should not be coded under CPT 37799, as indicated by the provider, and should be coded under well defined codes for sclerotherapy.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: At issue is whether genetic testing that was received was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. The patient had a history of right breast carcinoma and was status post right lumpectomy and axillary node dissection. She was treated with chemotherapy and radiation therapy. The patient subsequently underwent radiation therapy to the spine and to the lung mass.Findings:  Two out of three physician reviewers found that applying the National Comprehensive Cancer Network (NCCN) guidelines, this patient meets criteria for genetic testing due to being diagnosed with a breast cancer before age 50 and having metastatic disease. Genetic panel testing is now considered a standard of care. Carrying a mutation will guide screening, prognosis, as well as treatment decisions. One out of three physician reviewers found that in this case, the testing included a full 25 gene panel, which includes BRCA testing and several others. The additional genes included in this panel were not likely to have been of clinical benefit to this patient.Final Result: Two out of three medical experts determined that the requested genetic testing was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology, and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Motegrity 2 mg tablet.The submitted documentation supports the medical necessity of the requested medication for the treatment of this patients constipation. Per the records, she has had chronic constipation symptoms and failed Linzess. Motegrity has shown efficacy for the treatment of constipation and irritable bowel syndrome symptoms, including bloating and abdominal pain. The medical evidence indicates that Motegrity is safe and effective for the treatment of constipation, and this medication has proven effective in this patients case. Therefore, Motegrity 2 mg tablet is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for evaluation of the enrollee, who was asymptomatic. Findings:  The 3 physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for evaluation of his medical condition. Findings:  Three physician reviewers found that the genetic testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of large randomized trials supporting the use of genetic testing in this clinical setting. In addition, genetic testing is not clinically indicated for choosing and managing medication. The medical literature does not support the use of genotyping when choosing an antidepressant. Even less is understood about its utility in the treatment of anxiety disorders. In sum, genetic testing to determine psychiatric drug therapies lacks evidence-based research showing its effectiveness in choosing a medication regimen. Therefore, the gene testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 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 reviewers are board certified in psychiatry 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for treatment of the enrollees major depressive disorder, recurrent, severe without psychotic features, and generalized anxiety disorder.  Findings:  The physician reviewer found that applying the child and adolescent level of care utilization system (CALOCUS), which is an accepted, national standard for determining the appropriate level of care for children and adolescents, the RTC services provided were not and are not medically necessary for treatment of this patients medical condition. The patient endorsed passive suicidal ideation but denied any suicidal plan. The patient has a history of two suicide attempts. The patient had a co-morbidity of cannabis use which is likely contributing to her current psychiatric presentation. However, she has no other medical conditions that require significant medical monitoring. The patients parents are supportive. The patient has a limited ability to deal with stressors. Recovery has been maintained for moderate periods of time, but only with strong professional support. Developmental pressures create stress which the patient feels are very overwhelming. The patient is ambivalent about relationship with her providers. She frequently missed outpatient appointments and was on occasion non-compliant with treatment. 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prednisone for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case. Fibromyalgia is a chronic pain disorder that is treated with a number of non-pharmacologic and pharmacologic therapies provided in combination. These medications include selected antidepressants and selected anticonvulsant medications. Prednisone is U.S. Food and Drug Administration (FDA) approved for use in certain rheumatic disorders that cause chronic pain and debility.  It is FDA approved for use in an exacerbation or as maintenance therapy in selected cases of ankylosing spondylitis, dermatomyositis/polymyositis, polymyalgia rheumatica, psoriatic arthritis, relapsing polychondritis, rheumatoid arthritis, including juvenile rheumatoid arthritis, Sjogrens syndrome, systemic lupus erythematosus and vasculitis, as well as other conditions. However, the current medical evidence does not support the use of prednisone in this clinical setting. Prednisone is not indicated for the treatment of chronic pain caused by fibromyalgia. All told, prednisone is not medically necessary for the 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 internal 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: An enrollee has requested Orthovisc injections for treatment of the enrollees osteoarthritis. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with advanced osteoarthritis of the both knees.  Clinical examination findings are consistent with this diagnosis.  He has undergone two prior viscosupplementation series, with long-term pain reduction documented and improvement in ability to perform activities of daily living. He has failed to respond adequately to other conservative treatment, including anti-inflammatory medications and regular exercise. Therefore, the requested series of Orthovisc injections are medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services 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 orthopedic surgery 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 high dose radiation for treatment of the enrollees T1N0 estrogen receptor (ER) positive, progesterone receptor (PR) positive, infiltrating ductal carcinoma of the left breast. Findings:  The 3 physician reviewers found that accelerated partial breast irradiation (APBI) is a method for focused delivery of radiation therapy as opposed to the commonly applied whole breast irradiation approach. Whole breast irradiation is usually applicable to patients with invasive breast cancer who have undergone breast conservation surgery. APBI is applied as adjuvant therapy to prevent local recurrence of breast cancer. In 2010, a publication appeared showing that patients who were classified into the unsuitable category by the guidelines cited above had good outcomes with APBI. Colleagues published data showing that the categories established by the American Society of Radiation Oncology (ASTRO) guidelines did not show statistically significant differences in ipsilateral breast cancer recurrence. Finally, recent data colleagues evaluated 1,200 breast cancer patients after randomization into APBI versus whole breast radiation. Outcomes for breast cancer recurrence were not statistically different between the two cohorts with reduced skin toxicity in the cohort receiving APBI. Based on these compelling data and new rigorous medical evidence, APBI is an acceptable technique for use in this clinical setting. Thus, the high dose radiation provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in radiation 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 radiation 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 radiation 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: Experimental/Investigational
Decision: Overturned

A 60-year-old female enrollee has requested MyRisk gene panel testing (CPT code 81479-59) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the medical records noted a personal history of ovarian cancer.  Per the current guidelines, BRCA testing is warranted due to this patients history of ovarian cancer.  The MyRisk gene panel is a 25-gene panel which includes BRCA testing.  Although the documentation supports the BRCA testing portion of this panel, the records fail to demonstrate the superior efficacy of the remaining tests of the MyRisk gene panel testing.  Thus, a portion of the MyRisk gene panel testing performed was likely to have been more effective than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a sleep study test for evaluation of her history of daytime somnolence. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient presented with a clinical presentation that was suggestive of a sleep-related breathing disorder.  In this case, the patient had significant malocclusion, dental crowding and a large tongue.  Malocclusion has been linked to sleep-disordered breathing in recent publications.  The presence of an enlarged tongue is also considered to be a potential risk factor for sleep-disordered breathing. There is sufficient evidence that correction of these anatomical abnormalities can lead to improvement/resolution in sleep-disordered breathing.  Based on this patients anatomical presentation combined with her complaints of excessive daytime sleepiness, there was a clinically reasonable basis to suspect that she may have had obstructive sleep apnea.  Polysomnography is the standard diagnostic test in this clinical setting.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in sleep 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ExoDx Prostate Genetic Testing. The ExoDx urine exoxome genetic testing is available for men with elevated prostate specific antigen (PSA) to predict clinically significant prostate cancer. This testing is available in an attempt to avoid or proceed with prostate biopsy. However, prostate biopsy remains the most accurate diagnostic modality to detect prostate cancer. Furthermore, pathologic evaluation currently is the cornerstone to make prognosis regarding treatment options for prostate cancer. Therefore, the ExoDx Prostate Genetic Testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the ExoDx Prostate Genetic Testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the ExoDx Prostate Genetic Testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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.