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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the advanced lipoprotein testing for evaluation of the enrollees risk for heart disease. Findings:  Three physician reviewers found that this patient presents with baseline elevation of low density lipoprotein (LDL) cholesterol and non-high density lipoprotein (HDL) cholesterol but with negative risk factor of high HDL cholesterol. Advanced lipoprotein markers had been evaluated previously approximately six months prior. Reported clinical risk factor of family history of cardiovascular disease, but no report of diabetes, smoking, hypertension, or history of prior established cardiovascular disease. In some clinical circumstances, a single advanced lipoprotein analysis can sometimes be reasonable for assessment in intermediate risk individuals prior to any decisions regarding pharmacological therapy for cholesterol reduction, but this was performed six months prior. However, there is no evidence for repeated advanced lipoprotein analysis after the initial advanced risk assessment, and further lifestyle and/or pharmacologic therapy should be guided by both ongoing, unmodified, clinical risk factors and standard lipid profile monitoring of LDL and non-HDL cholesterol levels. Final Result: The 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: Reviewers 1, 2 and 3 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 90/400 mg 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 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: A. enrollee has requested reimbursement for genetic testing services (Prenatal Noonan Spectrum Disorder Panel).Findings:  Two of the three physician reviewers found Noonan syndrome is an inherited condition characterized by short stature, congenital heart defect, and variable developmental delay. Other findings include broad or webbed neck, cryptorchidism, varied coagulation defects, and ocular abnormalities. Congenital heart disease occurs in 50% to 80% of individuals with this condition. Pulmonary valve stenosis, often with dysplasia, is the most common heart defect. Hypertrophic cardiomyopathy may be present at birth or develop in infancy or childhood. Other structural defects include atrial and ventricular septal defects, branch pulmonary artery stenosis, and tetralogy of Fallot. Due to the potential severity of Noonan syndrome, genetic testing should be offered to women carrying fetuses with cystic hygroma. In sum, genetic testing services (Prenatal Noonan Spectrum Disorder Panel) were likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer 1 is board certified in clinical genetics and genomics and is actively practicing. Physician reviewers 2 and 3 are board certified in clinical biochemical genetics 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency surgery and related services on an emergent or urgent basis. Findings:  The physician reviewer found that according to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines for the Management of Hiatal Hernia, once the diagnosis of reflux is objectively confirmed, `surgical therapy should be considered in individuals who: 1) have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or medication side effects) or 2) opt for surgery despite successful medical management (due to quality of life considerations, lifelong need for medication intake, expense of medications, etc.) or 3) have complications of GERD (e.g., Barretts esophagus, peptic stricture) or 4) have extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration).` SAGES urges caution rather than urgency in pursuing surgical intervention. Specifically, the guidelines note the `average mortality rates for emergency hiatal hernia surgery are around 17% [whereas] the risk of developing acute symptoms requiring emergency surgery is probably less than 2% per year.` In this patients case, a letter from her provider indicates the patient underwent an upper endoscopy and did not undergo surgical intervention at that time.  As such, she did not meet the above definition of emergency medical condition, as the surgical procedure at issue was not performed on an immediate basis. Further, the submitted documentation does not demonstrate the patient was experiencing acute symptoms that necessitated immediate surgical intervention. Moreover, criteria for urgently needed services were not met in this case. Although the presence of impacted food was noted upon endoscopy, measures other than the disputed fundoplication procedure could have been utilized to prevent serious deterioration of the patients health until she was able to return to the her plans service area. Thus, the submitted documentation fails to establish that the services at issue were urgently needed. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for emergency care or urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  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 gene test (CPT 81420). Findings:  Three physician reviewers found that fetal aneuploidy screening is supported for pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Cell free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities including sex chromosomes. Currently, the non-invasive screening test of choice for aneuploidy is cell free DNA testing. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. The rate in the general population is 1:448. Sex chromosome abnormalities such as Turners syndrome include significant associated medical morbidities. Using the cell free DNA test to detect sex chromosome abnormalities is not an investigational procedure. This technique has been highly validated and shown to have a high detection rate. Early detection of fetal aneuploidy allows patients to make informed decisions about the pregnancy and select appropriate medical care. For these reasons, the gene test (CPT 81420) provided was likely to have been more efficacious for the evaluation of this patients medical condition than any available standard modalities. Final Result: 2 of 3 reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested sensory processing integration therapy for treatment of the enrollees autism and sensory processing disorder. Two physician reviewers found that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Sensory processing disorder is described as an overload of receiving sensory perceptions which in-turn leads to an over-response of behaviors.  The present concept is that an autistic patients abnormal behaviors stem from an over-response to environmental stimuli and treatment of his sensory processing disorder can only be treated by highly qualified and a specifically trained occupational therapist. Sensory integration therapy has a robust medical literature as to its long-term value. Miller and colleagues report significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children in a well-controlled study. In this case, the patient was specifically tested for sensory processing dysfunction and multiple sensory processing deficiencies were documented.  Given the support in the medical literature, sensory processing integration therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested therapy 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: One reviewer is board certified in pediatrics and neurology with sub-specialty certification in neurodevelopmental disabilities and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing.  One reviewer is board certified in neurology with special competence in child neurology and is 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

The patient is a 60-year-old male with minimal obstructive urinary symptoms and a benign feeling enlarged prostate on digital rectal examination. The patient underwent a transrectal ultrasound-guided biopsy on 10/7/04 because he had a slightly elevated PSA in the range of 5.0 to 5.3. This biopsy demonstrated a Gleason grade 6 (3+3) prostate adenocarcinoma in less than 5% of the tissue from the left side only. Thus, the staging is considered T1c for the patients prostate adenocarcinoma. The patient has requested that he be treated with a robotic-assisted laparoscopic prostatectomy. The Health Plan has denied this request indicating that a robotic-assisted laparoscopic prostatectomy is not medically necessary. The Health Plans denial should be upheld. To date, there is insufficient peer-reviewed medical literature demonstrating that robotic-assisted laparoscopic prostatectomy results in clinically superior outcomes. As such, the requested procedure is not medically indicated. Other appropriate surgical options exist for treatment of the patients condition. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

A 49-year-old female enrollee has requested eating disorder partial hospitalization program (PHP) services for treatment of her post-traumatic stress disorder (PTSD), bulimia, and depression.  Findings:  The physician reviewer found that the records indicate this patient has complex psychopathology and a tendency to deteriorate rapidly and severely when the level of care is reduced too quickly. Aside from her needs for psychotherapy, structure, and monitoring of her mood and suicide risk, she has been monitored using the Clinical Institute Withdrawal Assessment (CIWA) scale, a process that tends to require inpatient admission. Further, this patients potential for delirium tremens supports treatment at the PHP level of care. For these reasons, the PHP services were medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for enrollee admittance into a neuropsychiatric inpatient facility for observation and treatment. The submitted documentation supports the medical necessity of the requested services. The patient requires an evaluation done in a safe and controlled environment, by providers who are competent to assess the complications and risk of co-morbidities of autistic spectrum disorder. Moreover, the patient is at imminent risk of harm to himself or others. Non-epileptic seizure disorder is not a benign condition and requires expert evaluation and intervention in a controlled environment. Therefore, the requested admittance into a neuropsychiatric inpatient facility for observation and treatment is medically necessary for treatment of the patients medical condition.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 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 proton beam radiation therapy (CPT codes 77520 x 28, 77522 x 28, 77523 x 28, 77525 x 28, 77014 x 28, 77387 x 28, G6002 x 28, 77427 x 6, 77336 x 6, 77300 x 6, 77301 x 6, 77334 x 6, 77280 x 6, 77290 x 6, 76498 x 1, and 76497 x 1).Currently, there is insufficient clinical data to discern whether treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. A position statement released by The American Society of Radiation Oncology (ASTRO) stated, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy technique. In conclusion, proton beam radiation therapy (CPT codes 77520 x 28, 77522 x 28, 77523 x 28, 77525 x 28, 77014 x 28, 77387 x 28, G6002 x 28, 77427 x 6, 77336 x 6, 77300 x 6, 77301 x 6, 77334 x 6, 77280 x 6, 77290 x 6, 76498 x 1, and 76497 x 1) is not medically necessary for the 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 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 39-year-old female enrollee has requested breast cancer gene (BRCA1 and BRCA2) genetic testing for evaluation of her family history of breast cancer.  Findings:  Two physician reviewers found that the patient has a family history of breast cancer.  The submitted documentation indicates that the patients maternal aunt was diagnosed with breast cancer at age 45, and two maternal great aunts were diagnosed with breast cancer at age 70.  Per National Comprehensive Cancer Network guidelines, BRCA testing is indicated when there is a family history of a first or second degree relative diagnosed with breast cancer at age 45 or younger or when the patient has two or more third degree relatives with breast cancer.  Thus, this patient meets these criteria. Therefore, BRCA1 and BRCA2 genetic testing performed on the date in question was likely to have been the most efficacious tool for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parents of a sixteen year-old female with a progressive nasal congestion and deformity condition are requesting aurtorization for a rhinoseptoplasty, rib graft, and fascia graft.  Reviewers Findings:The reviewing physician found that the proposed procedures are clinically indicated to correct an abnormal structure caused by a congenital deformity and are necessary to improve function.  The reviewing physician found that the Health Plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for repeat bilateral L3-L4 facet joint injections and bilateral sacroiliac joint injections. Findings:  The physician reviewer found that lumbar facet blocks for the treatment of low back pain are increasingly used despite remaining controversial. There is no standardized diagnosis and treatment of facet mediated pain in routine clinical practice and in clinical trials, and there is a paucity of evidence in this area for patients who have previously had lumbar fusion. While facet mediated pain and its treatment remains highly controversial, the best diagnostic is a previous facet injection. In this case, the records note that the patient reported relief from two previous successful injections of the same kind and at the same locations, indicating that the L3 through L4 facets and sacroiliac joints are an important source of the patients pain. Chambers notes that while physiotherapy treatments may be of benefit in improving the longer-term outcomes of patients with chronic low back pain, it is not possible to make generalizations or firm conclusions regarding combination treatment of physiotherapy and injection therapy. While the use of physical therapy or of a home exercise program along with injection therapy may promote a healthy lifestyle, there is no particular data that mandates this particular combination of treatments. In this case, given that the records document relief from previous injections, the requested services are medically indicated. Therefore, repeat bilateral L3-L4 facet joint injections and bilateral sacroiliac joint injections are 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 neurological 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.