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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX prostate assay. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this clinical setting. This patient underwent genomic and protein biomarker testing (Oncotype Dx) to help in clinical decision making. The provider had recommended the testing in order to further evaluate risk of disease progression and prognosis. There are some studies that show that molecular and genomic testing appears to be helping those patients with low risk disease to make decisions regarding observation versus treatment. However, the drawbacks include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. This particular testing may be helpful in both low and high risk patients but the clinical benefit remains to be elucidated. The Oncotype DX prostate assay provided was not medically necessary for the evaluation of this patients medical condition. Final Result: The physician reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the wireless capsule test. Findings:  Three physician reviewers found capsule endoscopy was performed to evaluate for a possible small bowel polyp or tumor in a patient with known history of small bowel lesions and Peutz-Jeghers syndrome. According to the American Society for Gastrointestinal Endoscopy, evaluation for suspected small intestinal tumors is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging. Capsule endoscopy is reported as having high sensitivity in identifying small bowel tumors. Therefore, the wireless capsule test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the wireless capsule test performed 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 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: Overturned

A 32-year-old female enrollee has requested the medication, Lexapro (20mg) for treatment of her major depression. Findings:  The physician reviewer found that this patient has a seven-year history of symptoms of depression and presents with recurrence of symptoms. Symptoms at the time of her presentation for treatment included depressed mood, initial and terminal insomnia, anhedonia, tearfulness and excessive worrying. After effective treatment with Prozac for some years, the medication became ineffective (tachyphylaxis). After four weeks of Lexapro treatment, her symptoms showed significant improvement. Cipriani and colleagues and Yevtushenko and colleagues have shown that Lexapro is significantly more efficacious than citalopram in the treatment of major depressive disorder. Thus, the literature supports the notion that citalopram (one of the Health Plans alternatives) would likely have been less effective than the Lexapro that was prescribed and taken by the patient. Since the patient has already been started on a medication that has proven effective, it would not be medically prudent to switch her to a medication that may not be as effective.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old female enrollee has requested the Flexitouch System for the treatment of her postmastectomy lymphedema. Findings:  The physician reviewer found that although this patient meets criteria for a pneumatic compression device, there have been no randomized or controlled studies that demonstrate superior efficacy of the Flexitouch System as compared to standard pneumatic compression devices. Although the patient indicates she requires the Flexitouch System to treat her truncal edema, the Lympha Press System offered by the Health Plan can also be used to treat the trunk. There is no evidence that the requested device offers significant clinical benefit over the device offered by the Health Plan or that the device offered by the Health Plan will not meet the patients needs.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examinationFindings:  Two physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis to be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging. Thus, the addition of tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two 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 diagnostic radiology 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

The patient has requested authorization and coverage for Actemra (tocilizumab) 8 mg/kg (maximum dose 800 mg) intravenous (IV) monthly for six months. Researchers found that Actemra reduced total IgG and IgG1-3, and anti-HLA-total IgG and IgG3 levels in patients with chronic antibody mediated rejection (AMR). Medical literatures reported Actemra provided positive long-term results in patients with chronic poAMR. The authors noted that treatment with Actemra resulted in significant reductions in donor specific antibodies (DSAs) and stabilization of renal function at two-years. The records provided for review document chronic AMR. Testing has been consistent with persistent DSAs and a biopsy confirmed the presence of AMR. The provider recommended treatment with Actemra, IVIG, and a course of pulse steroids. Given the support in the medical literature, the requested Actemra (tocilizumab) 8 mg/kg (maximum dose 800 mg) IV monthly for six months is medically necessary for treatment of this patients medical condition. 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 surgery with expertise in transplant 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: Medical Necessity
Decision: Overturned

The parent of a 16-year-old male enrollee has for Vyvanse for treatment of the enrollees attention deficit/hyperactivity disorder (ADHD).   Findings:  The physician reviewer found that the FDA has approved Vyvanse for the treatment of ADHD. The age range specified in the package insert limits the age range that the manufacturer can use in advertising the product. The FDA does not regulate the practice of medicine and does not limit physicians to specific ages in the prescription of this drug. From a clinical standpoint, a patient 16 years of age is not very different from a patient 12 years of age in terms of expected response to a stimulant medication being used to treat ADHD. Moreover, this particular patient has demonstrated for a period of several months that he both benefits from and tolerates the drug in question. Accordingly, the patients treatment with Vyvanse is medically appropriate. It would be clinically inappropriate to ask him to switch to another compound merely because he is not in a particular age range. In view of his history, there is a reasonable expectation that such a switch may fail.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient was admitted for inpatient level of care. The patient reported that he had been engaging in self-harm via cutting. He was initially admitted after a physical altercation with his parents. The patient reported that he had an argument with his mother. The patients father reported that the patient had been out of control and physically aggressive. The records documented no prior inpatient psychiatric hospitalizations.  He was observed interacting appropriately and was calm and polite on evaluation. He reported feeling safe living at home and wanted to return home after his hospitalization. He denied thoughts of self-harm or psychotic symptoms. He reported feeling safe and comfortable in the psychiatric unit. Psychiatric progress notes noted a family meeting where the parents expressed feeling unsafe taking the patient home. The plan was to discharge the patient to a partial hospitalization program (PHP). The patients diagnoses included oppositional defiant disorder, attention deficit/hyperactivity disorder with a history of early childhood trauma, and maternal abandonment. The patients parent has requested reimbursement for the inpatient level of care. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient had a composite score of 17. This correlates with intensive outpatient services. Therefore, inpatient level of care was not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services were 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for whole exome sequencing. Findings:  The physician reviewer found that Whole exome sequencing (WES) is a newer technology but there is sufficient support in the medical literature for its efficacy in this clinical setting. Based on the patients documentation, she would be an ideal candidate for WES, given her multi-system disease, with renal agenesis, cortical dysplasia of the brain, biochemical abnormalities, and language delay. These multi-system findings increase the likelihood of an underlying single gene disorder, which can be identified by WES. Identification of a specific diagnosis in this patient may provide guidance for management in the future, including proper dietary management, which may be indicated for an inborn error of metabolism. A unifying diagnosis may also provide insight into helpful treatments for skeletal, renal, and developmental manifestations. Yang and colleagues identified causative diagnosis in 25 percent of 250 probands studied with WES. This yield is higher than genetic technologies previously considered standard, such as karyotype analysis or chromosomal microarray. A study  found similar detection rates. For these reasons stated above, WES is likely to be more effective than the available standard modalities for the evaluation of this patients medical condition. Final Result: All three reviewers determined that the requested services are 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 reviewers 1, 2 & 3 are board certified in pediatrics and 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of her 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni. 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for treatment of this patients hepatitis C virus 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam therapy (radiation therapy, 30 Gy in 20 fractions). The National Comprehensive Cancer Network (NCCN) guidelines support the use of photon-based radiotherapy in this clinical setting.  In this case, a proton/photon plan comparison showed that a photon-based plan meets all nationally accepted objectives in terms of normal tissue exposure and target coverage. Proton radiation is not proven to yield superior clinical outcomes in this setting. This patient can be safely treated with photon radiation. Therefore, proton beam therapy (radiation therapy, 30 Gy in 20 fractions) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld

The patients parent has requested reimbursement for wilderness residential treatment center (RTC) services. Applying the CALOCUS guidelines, this patient had a low risk of harm. The medical records indicate that the patient was not actively suicidal at any time. There was no indication that the patient was aggressive at any time during treatment. The progress notes did not indicate any active suicidal ideation, self-harm behaviors, or homicidal ideation. The patient demonstrated mild functional impairment as she had mild issues with level of function due to relationship problems with her family. She did not exhibit any significant behavioral problems, mood symptoms, or anxiety symptoms according to the records. The patient had minor comorbidity with a history of substance use that affects her primary psychiatric issues. The patient did not exhibit withdrawal symptoms or express cravings or urges to use substances. There was no indication of substance use during the treatment program. The progress notes indicate the patient presented to the treatment center with a history of depression and anxiety, and difficulty with relationships with peers and family. The patients recovery environment was mildly stressful as there was no indication of an unsafe home environment. The patients recovery environment was supportive as the records reported the patients family was actively involved in treatment on a regular basis. The patient demonstrated moderate response to treatment. The providers indicated that the patient engaged well at the RTC and her symptoms were under good control. There was no description of any significant mood or anxiety symptoms. The patient reportedly demonstrated limited response to prior treatment. The patient was constructive in treatment and was described as cooperative with good insight into her needs. The records noted that the patient was cooperative in treatment and engaged in individual therapy and family sessions. The patients parent was constructive and worked actively with providers on a regular basis. This patients composite score correlates with intensive outpatient services. Given these findings, the wilderness RTC services provided were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 subspecialty 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: Overturned

A 22-year-old female enrollee has requested Lexapro for treatment of her anxiety.  Findings:  The physician reviewer found that Lexapro is approved by the Food and Drug Administration (FDA) for the treatment of anxiety disorder and depression. Several peer reviewed medical studies including the publication from Bielski and colleagues, compared Lexapro to Paxil in the long-term treatment of anxiety. The authors concluded that treatment emergent adverse events were higher with Paxil than with Lexapro. The results support the use of Lexapro as a first-line treatment for generalized anxiety disorder. Another study by Boulenger and colleagues concluded that patients with anxiety with co-morbid severe depression responded significantly better to treatment with lower dose of Lexapro compared to a higher dose of Paxil. Another study by Bose and colleagues reported on the discontinuation syndrome due to adverse events was greater for Effexor XR compared to Lexapro. In this study, the researchers concluded that Lexapro was in fact better tolerated overall. Treatment with Effexor is also known to be associated with sustained increases in blood pressure in some patients. In summary, the scientific data supports the use of Lexapro as a first-line therapy in patients with anxiety. Thus, Lexapro should be both efficacious and better tolerated for this patients medical condition and therefore has been established as medically necessary in the management of her condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her fibrocystic breasts.  Two physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited. Thus, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two 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 diagnostic radiology 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.