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

A 57-year-old female enrollee has requested for a PET/CT fusion scan for evaluation of her primary peritoneal cancer.   Findings:  Two physician reviewers found that there is no data to support the notion that recurrent disease detected earlier improves overall survival unless perhaps an isolated mass is noted, which can be diagnosed with CT. Additionally, other modalities such as CT or MRI or tumor markers have utility in monitoring patients with ovarian or peritoneal cancer. In this case, the patients tumor markers are in the single digits. Unless her CA-125 is not instrumental in following her disease (i.e., never elevated at presentation) there is no benefit to performing a PET/CT scan. There are other markers that can be followed depending on the original histological subtype (i.e., mucinous including CA 19-9). Additionally, PET scans have poor resolution in tumor sizes less than 7mm.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for FoundationOne CDx genetic testing. In addition to likely providing prognostic information, there are data to support the utility of next generation sequencing to predict candidates for specific mutation-driven treatment. Specifically, patients with inflammatory and metastatic breast cancers have been shown to benefit from next generation sequencing to identify markers that may be targeted for treatment or for enrollment in clinical trials. For this patient, testing for mutations with tumor or liquid biopsy was appropriate to identify whether the patient is a candidate for treatment with alpelisib. Testing for BRCA mutations, mismatch repair (MMR), microsatellite instability (MSI) was indicated to help identify possible targeted therapies. Based on the medical literature, the use of next generation sequencing with FoundationOne was reasonable in this patients clinical setting. Therefore, the FoundationOne CDx genetic testing was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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 birth defects (fetal aneuploidy trisomy risk) for the evaluation of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Cell-free DNA testing is not currently recommended for low-risk patients.  High-risk criteria which support the services at issue include 35 years of age or older at the time of delivery, sonographic findings associated with fetal aneuploidy, history of previous pregnancy with fetal trisomy, parental balanced robertsonian translocation with increased risk of trisomy 21 or 13, and screen-positive result for aneuploidy on screening tests such as the first trimester combined test, integrated test, sequential test, or quadruple test.  In this case, the records do not document risk factors which would support the services at issue.  Other covered screening modalities were available to this patient.  In sum, the genetic testing for birth defects was not likely to have been superior over other available modalities for evaluating this patient. Final Result: 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: All three reviewers are board certified in obstetrics and gynecology 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: Overturned

A 41-year-old female enrollee requested authorization and coverage of gastric bypass surgery for the treatment of morbid obesity.  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 surgery is  medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The father of a 17-year-old male enrollee requested authorization and coverage of nasal surgery. The Health Plan  denied the request indicating that the requested procedure is not medically necessary for treatment of the enrollees nasal obstruction.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the Health Plans denial on the basis that the requested procedure is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyperbaric oxygen therapy (G0277). Francis and Baynosa noted that hyperbaric oxygen has demonstrated utility in the salvage of compromised grafts or flaps and can increase the likelihood and effective size of composite graft survival, improve skin graft outcomes, and enhance flap survival. Bennett and colleagues have found that hyperbaric oxygen therapy may be used to treat cancer survivors who experience late radiation tissue injury. In this case, the patient has a chronic non-healing wound that was exacerbated by cancer recurrence, surgery, and prior radiation. Although she previously underwent hyperbaric oxygen therapy, the wound has worsened and may require flap surgery. Based on current medical literature, hyperbaric oxygen therapy is medically indicated to prepare for a flap or graft, and when there is evidence of significant soft tissue damage related to radiation. Therefore, hyperbaric oxygen therapy (G0277) is medically necessary 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 reviewer is board certified in family medicine with sub-specialty certification in undersea and hyperbaric 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: Upheld

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program level of care services provided.  Findings:  The physician reviewer found that the level of care was analyzed utilizing the Level of Care Utilization System (LOCUS) for Psychiatric and Addiction Services. This is a nationally accepted system for determining appropriate level of care. Recent gains and/or stabilization in function have been achieved while participating in treatment in a structured setting. Regarding medical, addictive or psychiatric comorbidity, the patient had a significant comorbidity with diagnoses of methamphetamine use disorder and sedative hypnotic use disorder. The patient had a mildly stressful recovery environment, as he had some mild interpersonal conflict with his partner. The records document a supportive environment.  In terms of treatment history, the documentation noted a moderate response to treatment. The patient participated in a 28-day program in 2013 and a 90-day program in 2014. Regarding his engagement and recovery status, the patient has been engaged and motivated for treatment and recovery. Based on LOCUS, the patient would meet criteria for intensive outpatient program level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 23-year-old male enrollee has requested cognitive rehabilitation/speech therapy for the treatment of his traumatic brain injury. Findings:  Three physician reviewers found that the patient suffered a very severe traumatic brain injury and as a result he has significant cognitive deficits including word retrieval, processing, attention, and memory. Cognitive remediation by a speech therapist is standard therapy at most, if not all acute rehabilitation facilities including outpatient brain injury programs. Research data is generally supportive of cognitive rehabilitation in the young, awake, and brain-injured patient. There are no alternatives to this standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl patch 50 mcg for treatment of the enrollees chronic nerve pain.  Based on the documentation submitted for review, fentanyl patch 50 mcg has not been established as medically necessary for treatment of the patients medical condition. The requested dosage and quantity are indicated for malignant pain. The medical records show the patient has chronic non-malignant pain. The current standard of care for chronic nerve pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. Therefore, based on current medical literature and in consideration of the presented clinical records, fentanyl patch 50 mcg is not 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 anesthesiology with sub-specialty certification in pain 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: A male enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/ Case Summary:  According to the records, the enrollee is requesting excision abdomen skin infraumbilical panniculectomy. The record indicates the enrollee lost over 200 lbs. by eating a vegetarian diet. She has maintained a weight of 175 lbs. She has excess abdominal skin (pannus) from the weight loss, which causes pain and rashes that itch (pruritic intertrigo). She has tried multiple different creams and powders (seven total), as well as oral medications, but none were effective at resolving the skin condition. Her nurse practitioner states that she has chronic dermatitis and skin degeneration underneath the pannus that causes hives and blisters, which are difficult to treat leading to areas of open wounds. Treatment for pannus rashes has failed. This condition limits her abilities to perform daily activities, such as walking, cleaning, and shopping for groceries. Her skin condition has never completely resolved because it is made worse by the skin-to-skin contact from her pannus and the enrollee would greatly benefit from surgery to remove the excess abdominal skin.  A review of the record substantiates this enrollees condition meets the expanded concept of medically necessary reconstructive surgery defined in California law. The record indicates recurrent infection, dermatitis and skin degeneration under the pannus that persist despite application of numerous creams and powders. Conservative management of this condition has not been successful and impairs the enrollees ability to function.  The medical evidence supports the panniculectomy is medically necessary for the treatment of this enrollee. A note from the provider indicates the pannus limits the enrollees ability to walk and manage her home. The alleged abnormality, pannus, constitutes an abnormal structure of the enrollees body, which results from treatment of her disease (obesity). The surgery will create a normal appearance to the extent possible and provide more than a minimal improvement in the patients appearance. The American Society of Plastic Surgeons indicates panniculectomy has been shown to improve functional quality of life and ability to perform activities of daily living. It should be considered a reconstructive procedure when performed to improve skin health within the fold beneath the pannus. A review of the record substantiates the requested surgery, excision abdomen skin infraumbilical panniculectomy, is reconstructive in nature and will improve function.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition and is reconstructive in nature.Credentials/Qualifications: The physician reviewer is board certified in Plastic 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

A 27-year-old male enrollee has requested acute inpatient psychiatric services for treatment of his schizophrenia and post-traumatic stress disorder. Findings:  The physician reviewer found that based on review of the available records, the progress notes for the acute inpatient psychiatric services indicate that the patient was still unstable and required treatment at this level of care. The patients mood was changing frequently and his command auditory hallucinations continued. He admits that he was at risk for hurting other people if not in a structured environment. He did continue to develop coping strategies and insight as his thought processes cleared with the medication changes. By the indicated date, he was considered stable enough to be discharged without fear that he would harm someone else. However, the patient was not stable enough for discharge, and his command auditory hallucinations made him a risk to the safety of others. For these reasons, the acute inpatient psychiatric level of care services were medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the prenatal genetic testing (gene panel testing) for evaluation of the enrollees pregnancy. Findings:  Three physician reviewers found that genetic testing is becoming more widely available and now offers expanded carrier screening panels for ethnicity based and general population carrier screening. Use of this technology provides information regarding more conditions than the currently recommended screening guidelines. Of note, the professional practice guidelines recommend offering carrier screening for individual conditions based on condition severity, race or ethnicity, prevalence, carrier frequency, detection rates, and residual risks. At present, the American College of Obstetrics and Gynecology (ACOG), the American College of Medical Genetics and Genomics (ACMG), and the National Society of Genetic Counselors recommend panethnic screening for cystic fibrosis. The ACOG and ACMG also recommend Fragile X syndrome carrier screening for patients with a family history suggestive of Fragile X syndrome. However, advanced maternal age alone is not an indication for expanded carrier screening. 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 physician reviewers are board certified in obstetrics and gynecology 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

A 41-year-old male enrollee has requested a Prodisc-C procedure (artificial disc replacement) for treatment of his chronic cervical radiculopathy involving C5-C6.  Findings:  Three physician reviewers found that in an assessment of the safety and efficacy of cervical disc arthroplasty (replacement), Matz et al. performed a systematic review of the literature in which they examined 10 studies that reported outcomes of arthroplasty compared to preoperative function or anterior cervical discectomy with fusion (ACDF).  Mummaneni et al. reported that when all criteria for success were used, the arthroplasty group had a superior outcome; however, multiple confounding factors, such as the use of medications, cervical collar immobilization, patient expectations, and lack of blinding, prevented any conclusions from being drawn. This study was downgraded to Class II evidence. Studies by Porchet and Metcalf (55 patients), Hacker (46 patients), and Coric et al. (33 patients) all reported randomized series of patients with cervical degenerative disease who underwent either arthroplasty or ACDF. These individual reports were subgroups of patients included in a larger randomized controlled trial. In these studies, both the arthroplasty and ACDF groups showed clinical improvement without significant differences between groups at 24-months postoperatively on the Neck Disability Index (NDI) and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). More recently, published reports of randomized trials with longer term follow-up do suggest that artificial disc replacement may be beneficial; however, the percentages of patients receiving 4 year and 5 year follow-up are exceedingly low and call into question the overall validity of the findings at this time (Delamarter et al. and Burkus et al.). As such, artificial disc replacement is still considered inferior to other proven modalities in this setting.
Appeal type: Medical Necessity
Decision: Overturned

SummaryThe patient is a 53-year-old female who has had bilateral below-the-knee amputations and amputation of the left thumb and right index finger, and right hip avascular necrosis.  She also has 90 degree contractures of the metacarpals and impaired web-space opening with the left hand such that she is not able to grasp objects greater than two inches in size.  She is requesting reimbursement for the cost of equipment and installation of the Bruno Electra-Ride III stair lift.  The Health Plan denied her request citing a lack of medical necessity.Clinical Facts:  The patient has had bilateral below-the-knee amputations and amputation of the left thumb and right index finger at the distal phalanx. The record also indicates she has 90 degree contractures of the metacarpals and impaired web-space opening with the left hand such that she is not able to grasp objects greater than two inches in size. The patients grasp strength was 21 pounds on the right and 13 pounds on the left when she was evaluated in July 2005. She has Herrington rods from T4 to T2 with decreased mobility of the spine. Furthermore, the patient has right hip avascular necrosis with limited range of motion in both hips and she has a history of medial meniscus injury to her right knee. Reviewers Findings:The physician reviewer indicated that patient has a complex medical history and considering her various medical conditions, it would be extremely difficult for her to safely ascend or descend stairs even while holding onto the railing with both hands. For this reason the reviewer has concluded that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

A 39-year-old male enrollee requested authorization and coverage for Silikon 1000 injections. The health plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees lipodystrophy.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer overturned the health plans denial on the basis that the requested injections are medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has requested bilateral reduction mammoplasty for treatment of the enrollees gynecomastia. Findings:  The physician reviewer found that the patients breasts were enlarged due to a developmental abnormality. Reduction mammoplasty was performed, not to enhance, but rather to normalize his appearance. Surgical intervention was consistent with the ASPS guidelines as the patient had grade III gynecomastia that had persisted for longer than one year and his endocrine evaluation was normal.