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

The parent of a 13-year-old male enrollee has requested Nutropin AQ for the treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that while it appears that the patients growth slowed significantly, there is no evidence of a recent IGF-1 and bone analysis, no documentation of clear growth rates, and no recent adult height prediction against his expected mid-parental height of 59.5. In the absence of such evidence, it is not possible to confirm a neurosecretory GH deficiency that would necessitate the use of GH therapy. All told, the submitted evidence does not demonstrate that the patient meets criteria for growth hormone therapy at this time.
Appeal type: Medical Necessity
Decision: Upheld

A 30-year-old female enrollee requested authorization and coverage for the medication Lamisil for the treatment of a fungal infection of the toenails on both feet.  The health plan has denied this request indicating that Lamisil is not medically necessary for treatment of the enrollees medical condition.One podiatry reviewer performed a medical necessity Independent Medical Review.  The podiatry reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

A 46-year-old male enrollee has requested Sculptra injections for the treatment of his lipoatrophy secondary to AIDS. Findings:  The physician reviewer found that this patient has facial lipoatrophy as a result of HIV infection and treatment with antiretroviral medications. Sculptra is considered safe and effective for treatment of the patients condition and is considered medically necessary for HIV patients to correct deformities resulting from loss of fat. Thus, the initial injections the patient received were medically necessary and should be covered by the Health Plan. However, given that this patient has already received two injections of Sculptra with good results, additional Sculptra injections are not indicated at this time. Photographs show an essentially normal facial contour with only minimal changes evident around the patients mouth. As noted in the Burgess and colleagues study, it was often the case that the desire for further dermatological enhancement was purely subjective. Based on a review of the submitted clinical evidence, the patients condition does not warrant additional Sculptra treatments at this time.
Appeal type: Experimental/Investigational
Decision: Upheld

A 48-year-old male enrollee requested a two-level cervical total disc replacement (arthroplasty) for medical treatment of his medical condition.  Findings:  Three physician reviewers found that artificial total disc replacement versus fusion for the cervical spine has not been proven to be more beneficial in the treatment of patients with spine pathology.  Multiple studies are currently being undertaken to determine the efficacy and safety of cervical arthroplasty.  As such, there is a lack of medical evidence to indicate that the proposed two-level cervical total disc replacement would be more beneficial than a standard anterior cervical discectomy and fusion in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has a history of delayed gross motor milestones and has a diagnosis of congenital myopathy. An occupational therapy evaluation noted hypotonia in both arms. She was independent with most basic tasks, except for more challenging tasks such as managing snaps for dressing and opening food containers. She had a shower seat but was not using it. She was wearing a spinal brace. On examination, vision and hearing were within functional limits. Upper limb strength was three plus to four plus out of five. A physical therapy evaluation noted that the patient was independent with transfers and ambulation. The patient had severe dextroscoliosis. Her standing tolerance was approximately 10 minutes. She was ambulating at a slower pace due to fatigue. The patient was able to walk approximately one block in the community before experiencing fatigue and requiring a sitting break. The patients leg strength was rated as three plus to four plus out of five. End range tightness in the hamstrings and gastrocnemius muscles was noted. The patient has requested coverage for a power wheelchair with accessories. The Health Plan denied the request and reported the requested device is not medically necessary for the treatment of this patient. At issue is whether the requested power wheelchair with accessories is medically necessary for the treatment of this patient. The patient has motor impairments and has been diagnosed with myopathy. There have been complications or consequences that include scoliosis and functional deficits.  The patient has been independent with most aspects of mobility, including managing at school with accommodations. The patients difficulties revolve around longer distance community mobility. She requires rest breaks for ambulation greater than one block. There are no indications that her higher level mobility needs would not be met with a manual wheelchair, which would provide better general accessibility. The patient does not require a power wheelchair with accessories for accomplishing her mobility-related activities of daily living. The medical evidence does not support the requested device in this clinical setting. Therefore, the requested power wheelchair with accessories is not medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 12 months of treatment at Sunrise Residential Treatment Center for dialectical behavior therapy. Findings:  The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. The patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, 12 months of treatment at Sunrise Residential Treatment Center for dialectical behavior therapy 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 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: Overturned

A 43-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

A 20-year-old female enrollee has requested breast reduction surgery for treatment of back pain.  Findings:  The physician reviewer found that there is no photographic evidence of shoulder grooving or skin changes related to the patients large breasts. There is very limited documentation of conservative treatment of the patients back pain such as non-steroidal anti-inflammatory drugs, physical therapy, support garments or medically supervised weight loss attempts.
Appeal type: Experimental/Investigational
Decision: Overturned

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. As such, the use of 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 diagnostic procedure 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: 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.
Appeal type: Medical Necessity
Decision: Upheld

The enrollee requested authorization and coverage for Prolia injections for osteoporosis. The patients internal medicine specialist indicated the enrollee cannot take Fosamax because of gastrointestinal upset. The recommendation was for the enrollee to start Prolia. The enrollee has very poor intravenous access and significant anxiety regarding intravenous catheter insertion. Prolia is used for the treatment of postmenopausal women with osteoporosis who are at high risk for fracture; treatment of glucocorticoid-induced osteoporosis in women at high risk for fracture; and treatment to increase bone mass in women at high risk for fracture receiving adjuvant aromatase inhibitor therapy for breast cancer. Medical literature indicates Prolia is not considered initial therapy for most patients with osteoporosis. Initial therapy for patients includes lifestyle measures and oral bisphosphonates. The medical literature indicates Prolia is for postmenopausal women with osteoporosis who are at high risk for fracture, defined as a history of osteoporotic fracture, or who multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. The medical literature indicates a patients having gastroesophageal reflux disease does not mean they cannot take bisphosphonates. However, when gastroesophageal reflux disease is active, bisphosphonates are more difficult to use. Osteoporosis medications given intravenously instead of orally can help with gastrointestinal side effects. There is insufficient evidence in the record the enrollee has tried and failed bisphosphonates. There is also insufficient evidence the enrollee has a contraindication to the use of bisphosphonates, such as esophageal disorder or inability to sit upright for 30-60 minutes or chronic kidney disease. Denosumab is considered more effective than bisphosphonates only in cases where the patient has renal insufficiency. Since this enrollee does not have renal insufficiency or documentation of intolerance to oral bisphosphonates, bisphosphonates are still considered the first-line treatment for this enrollees osteoporosis. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in endocrinology and 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 DecisionDx-Melanoma testing (CPT-81599). Findings:  Three out of three physician reviewers found that commercially available gene expression profiling (GEP) testing, such as the DecisionDx-Melanoma test, has been marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, micro satellites, and sentinel lymph node biopsy (SLNB) status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, SLNB, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models (i.e., the AJCC 8th edition melanoma risk calculator/prognostic tool in development). Accordingly, the DecisionDx-Melanoma test (CPT-81599) at issue was not likely to have been more beneficial than any available standard treatments for the patients medical condition.Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial than any available standard treatments for the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine, with subspecialty certification in hematology and 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: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg tablets for eight weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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: An enrollee has requested reimbursement for the Acessa procedure. Acessa is a new U.S. Food and Drug Administration (FDA) approved procedure for the treatment of uterine fibroids. It is not a commonly adopted procedure and has not been shown to be more efficacious than existing therapies. In fact, few studies to date have been conducted on its adverse outcomes. At this time, due to its lack of nationwide adoption, the American College of Obstetricians and Gynecologists (ACOG) fails to comment on the subject of radiofrequency ablation of uterine fibroids. However, the Society of Obstetricians and Gynaecologists of Canada (SOGC) notes in their 2015 guidelines on the management of uterine leiomyomas that of the conservative interventional treatments currently available, uterine artery embolization has the longest track record and has been shown to be effective in properly selected patients. The SOGC note that newer focused energy delivery methods are promising but lack long-term data. The American College of Obstetricians and Gynecologists (ACOG) recommends that medical therapy is attempted prior to more invasive therapies.In this case, there is no documentation that the patient failed medical therapy or that medical therapy was contraindicated prior to surgical intervention. The submitted documentation does not reflect that this patient had failed or was contraindicated to receive an intrauterine device (IUD), the oral contraceptive pill (OCP) or gonadotropin-releasing hormone (GnRH) agonist therapy prior to the surgical intervention at issue. Under these circumstances, the Acessa procedure was not medically necessary to treat the patients medical condition.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 obstetrics and gynecology 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 reimbursement and prospective authorization and coverage for (1) acupuncture services received (2) acupuncture services received (3) acupuncture services from three times per week. Findings:  The physician reviewer found that Acupuncture is effective for the treatment of chronic musculoskeletal, and osteoarthritis pain. Per the authors, Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain. Kelly and Willis note that, for certain patients, especially those who are unresponsive or intolerant to standard therapies, acupuncture is a reasonable treatment option. Following an acupuncture trial of five or six sessions, additional acupuncture treatments should only occur based on progressively greater, incremental objective gains. Acupuncture should be combined with active care, such as conditioning, aerobics, and/or a stretching exercise program. Indications for care discontinuation include resolution, intolerance, lack of measurable improvements, or non-compliance including non-compliance with aerobic and strengthening exercises. In this case, while the patient reported benefits from prior acupuncture, the records did not document pre-acupuncture and post-acupuncture baselines for comparison purposes, and measurable, progressive, significant, or objective functional improvement. The documentation did not demonstrate significant medication intake reduction, or improvement of activities of daily living functioning directly attributable to prior acupuncture. The records did not document that the patient was undergoing an independent exercise program. Given that measurable, progressive, significant, objective functional improvement has not been documented, the services at issue were not and are not medically indicated. Therefore, (1) acupuncture services received and acupuncture three times per week were not and are not medically necessary for the treatment of this patient.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 acupuncturist, board certified in oriental 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

A 58-year-old female enrollee has requested for bariatric surgery for treatment of her morbid obesity. Findings:  The physician reviewer found that the patient does not meet nationally accepted criteria for authorization of bariatric surgery. Her BMI is less than 35 and she is not 100 pounds over her ideal body weight. Her sleep apnea symptoms have not been documented by a formal sleep study and there is no evidence that she has been fitted for CPAP. In addition, no fasting glucose has been submitted demonstrating the patient is diabetic. Furthermore, given the patients current condition there is a good chance that she can lose weight through conservative means.
Appeal type: Experimental/Investigational
Decision: Upheld

A 23-year-old male has requested coverage for a past Chemo FX Assay for evaluation of his appendiceal mucinous neoplasm.  Findings:  Three physician reviewers found that the patient was diagnosed with well-differentiated mucinous adenocarcinoma of the appendix two years ago.  In an effort to select a chemotherapeutic regimen, his tissue was submitted for a Chemo FX Assay.  Chemo FX Assay is used to determine the likelihood of efficacy of a specific chemotherapeutic agent.  This is done by testing the growth of a patients cancer cells in an environment of various agents in vitro.  Many of these types of assays have been developed.  However, it has not been demonstrated that selecting a specific chemotherapy regimen under the guidance of this assay results in significantly better survival when compared to a regimen based on known clinical studies and standards.  Much of the work regarding the testing at issue has been done in ovarian cancer.  However, even in cases of ovarian cancer, National Comprehensive Cancer Network guidelines state that there is insufficient evidence supporting the use of information from these assays to supplement standard of care chemotherapy.  There is less data regarding the use of the testing at issue for other forms of cancer, including appendiceal cancer.  The current medical evidence has not demonstrated that the testing at issue will lead to superior outcomes.