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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing provided for evaluation of the enrollees lung cancer. Findings: Threee physician reviewers found that multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample, instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. The National Comprehensive Cancer Network Non-Small Cell Lung Cancer Guidelines Panel strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling is considered a standard of care.  In sum, genetic testing provided was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All three 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 42-year-old female enrollee has requested authorization for hip resurfacing arthroplasty for treatment of her post-traumatic arthritis.  Findings:  Three physician reviewers found there have been significant design improvements during the last decade. At this point in time, hip resurfacing with metal-on-metal implants is promoted as an alternative to total hip replacement for younger patients with osteoarthritis or avascular necrosis who would like to maintain a more active lifestyle.  In May 2006 the Food and Drug Administration approved the Birmingham Hip Resurfacing System. It is likely that within several months the remainder of the surface implants will be approved as well. Hip resurfacing at this juncture should not be considered investigational or experimental. The procedure represents a viable option for patients with disabling arthritis. Very young patients such as this one can be expected to derive more benefit from hip resurfacing than a conventional hip replacement.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) (CPT 77338 x 3, 77301 x 1, and G6015 x 25) at a dose of 79.2 Gray (Gy). This patient presents with prostate cancer. He has been treated with androgen deprivation therapy and his provider recommended IMRT. Researchers noted that IMRT is a curative treatment modality for localized prostate cancer. However, prospective data has yet to validate a role for IMRT in the treatment of metastatic prostate cancer. There is a paucity of data in medical literature to support a role for IMRT in the treatment of this patients prostate cancer. All told, the requested IMRT (CPT 77338 x 3, 77301 x 1, and G6015 x 25) at a dose of 79.2 Gy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested IMRT (CPT 77338 x 3, 77301 x 1, and G6015 x 25) at a dose of 79.2 Gy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Transoral Incisionless Fundoplication (TIF) procedure utilizing the EsophyX device. Findings:  Three physician reviewers found that the requested TIF procedure utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While the efficacy of the TIF procedure has been studied in randomized controlled trials, the conclusions are contradictory. One large randomized trial that included 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months. In this trial, normalization of pH was accomplished in only 29 percent in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61 percent. The study concluded that although TIF resulted in a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved. A recent meta-analysis has concluded that further safety and efficacy comparison is needed to directly compare TIF with conventional treatment such as Nissen fundoplication. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) report that the long-term follow-up data for TIF is limited. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. For these reasons, the requested TIF procedure utilizing the EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the requested procedure is 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: 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 23-year-old female enrollee has requested sub-acute residential eating disorder treatment for the treatment of her behavioral health problems. Findings:  The physician reviewer found that despite the current residential treatment, the patient has not improved to any significant degree.  In addition, it seems unlikely that she will improve at Pacific Shores given what the submitted records report of her stay to date. The records are inconsistent and vague and do not indicate a clear, coherent, and thought-out plan of treatment. Her medications have been changed frequently, without an adequate therapeutic trial of a given medication or dosage. In addition, she was diagnosed with ADD at Pacific Shores, and was started on Adderall, a stimulant with significant anorexia as a side effect. She was also started on Provigil, presumably due to excessive sleepiness (which may well be a manifestation of her depression). Provigil is also a central nervous system stimulant that can cause or aggravate anorexia. Thus, there is limited potential for improvement at the current facility. The patient may well benefit from placement at an alternative residential treatment center that can provide intensive psychiatric treatment for her depression and obsessive compulsive disorder, as well as medication monitoring and necessary treatment for her eating disorder. The Health Plans current alternative is intensive outpatient treatment at the Pacific Shores facility. This alternative does not appear to be appropriate for this patient. She has not demonstrated stability at the current level of care (residential treatment) and her eating disorder has not stabilized to allow transition of care to a lower level of treatment. In addition, in view of the Plans concerns for the lack of patient progress at Pacific Shores, continued treatment at that facility at a lower level of care is not likely to lead to progress and would not provide the same level of structure which she is currently requiring. Therefore, since the current treatment is more appropriate for the patient than the Plan offered alternative, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for intensive outpatient program (IOP) services. Findings:  The physician reviewer found that the patient presented on intake as sober with no signs of withdrawals. Although the patient showed no behavioral aberrations and was cognitively intact, the patient's drinking impacted negatively upon his marriage. The patient was motivated to change. The patient had extended periods of sobriety, but relapsed. The patient has previously been treated with one IOP treatment and limited Alcoholics Anonymous experience. The patient has a history of opiate addiction. Based on the documentation submitted for review, IOP services are medically necessary in this clinical setting to educate the patient regarding the nature of addiction, development of coping skills, and relapse prevention. The patient requires a more structured and intense setting for treatment than outpatient services can provide. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: The patient has requested reimbursement and prospective authorization and coverage for Long-term acute care hospital (LTACH) services. LTACH level care is intended for patients who require care that is more medically complex than can be provided at lower levels of care, such as inpatient rehabilitation, or SNF levels of care. LTACH level of care includes provision of chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care, ventilator weaning, and frequent imaging and laboratory testing. In general, more than one of these treatments is being provided at the LTACH level of care. There should also be documentation of prior treatment failure at lower levels of care or reasonable expectation of treatment failure at lower levels of care. This patient had a persistent ulcer, complicated by osteomyelitis that failed initial management with hospitalization, SNF care, and outpatient wound clinic follow-up. She was transferred to an LTACH for further care given her multiple concomitant complex medical issues having failed less intensive therapy. By the first date of denial, she had completed her antibiotics and there was no indication that her right heel wound had worsened or required acute hospital care. She was stable on chronic hemodialysis and required only maintenance management. She has other longstanding issues such as impaired function due to multiple strokes, depression, hypertension and diabetes. However, there is no evidence of active issues that require acute hospital level of care. Her laboratory studies have stabilized, with stable anemia at her goal hemoglobin level, resolved reactive thrombocytosis, and stable renal and hepatic profiles. The records indicate that she is on hemodialysis and has a persistent wound, but these stable issues are chronic and do not require LTACH level of care. There are no more complex medical treatments, or need for frequent testing beyond maintenance monitoring. Renal service has recommended weekly laboratory testing. All told, the LTACH services were not and are not medically necessary for 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 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 patient has requested authorization and coverage for Cosentyx Sensoready 300 mg solution autoinjector. Systemic treatment of patients with psoriasis is indicated when topical treatments fail or do not achieve  sufficient control of disease. There are several U.S. Food and Drug Administration (FDA) approved systemic options for patients with moderate-to-severe psoriasis. The FDA treatment options include non-biologics and biologics. Armstrong and colleagues found that the non-biologics have worse efficacy than the biologics. This patient has been treated with tried Otezla with initial relief, but it has lost its efficacy. The patients provider has recommended treatment with Cosentyx. However, the records do not document adequate treatment or a contraindication to medications recommended for the treatment of patients with moderate-to-severe psoriasis. Lockshin and colleagues noted that ixekizumab has the greatest prolonged drug survival of tumor necrosis factor (TNF) inhibitors. On review of the available documentation and current medical literature, the patient is a candidate for treatment with an interleukin-17 (IL-17) or IL-23 biologic. Moreover, there is a lack of data reporting superior health outcomes with one IL-17 or IL-23 agent over another. The clinic notes dated 5/31/22 mention the patients concern about malignancy risk for Tremfya, which has been reported to be low (Blauvelt, et al.). All told, the requested Cosentyx Sensoready 300 mg solution autoinjector is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dermatology 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 a power operated wheelchair. The Health Plan has denied this request indicating that the requested equipment is not medically necessary for the enrollees mobility.Findings: The submitted documentation fails to demonstrate the medical necessity of the requested equipment. The standard criteria for use of power mobility equipment generally involves severe weakness of the upper extremities due to a neurological or muscular disease and/or condition such as a spinal cord injury, cerebral palsy, multiple sclerosis, or stroke with residual dense hemiplegia. Such patients may qualify for coverage of a power wheelchair or scooter if they have paralysis or severe weakness of their arms and legs. Patients whose diagnoses are limited to non-neurological conditions such as chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, arthritis, or obesity rarely meet the standard criteria for coverage of a power operated wheelchair. In this patients case, although he has a history of end stage renal disease and the patient likely has a fistula for dialysis, the documentation has noted that he is currently able to use a manual wheelchair. It does not appear from the records that this patient has severe weakness of his upper extremities. In addition, he is residing in an accessible skilled nursing facility where his mobility deficits can be appropriately addressed through the use of standard mobility aides. Therefore, the request for a power operated wheelchair has not been established as medically necessary for management of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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: Experimental/Investigational
Decision: Overturned

A 59-year-old female enrollee has requested Oncotype DX testing performed for evaluation of her breast cancer.   Findings:  Two physician reviewers found that the Oncotype DX assay is a 21-gene profile used for women with node negative, ER positive breast cancers between 6 mm and 4 cm in order to determine the risk of recurrence. It is intended to assist in making an appropriate decision regarding adjuvant chemotherapy treatment and has been found to be efficacious for this purpose. Based on this patients tumor size, ER positive and negative node status, she met clinical indications for the Oncotype DX assay.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the procedure to freeze tissue (cryosurgical ablation) of a tumor on the chest wall for treatment of the enrollee who has a history of primary mediastinal high grade spindle cell sarcoma.  Findings:  Two physician reviewers found that there is some support for the procedure at issue in this clinical setting. The submitted documentation indicates that this patient has already undergone numerous rounds of chemotherapy and radiation therapy for the treatment of his condition. In 2016, microwave ablation was successfully performed to treat an LUL nodule. There is sufficient peer reviewed literature to support that cryosurgical ablation of the T11 paravertebral mass would lead to a better outcome than any available standard therapy. For these reasons, the procedure to freeze tissue (cryosurgical ablation) of a tumor on the chest wall was likely to have been a better option than standard medical therapy for the treatment of this patients medical condition. Final Result: The reviewers determined that the procedure at issue was 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: Reviewer number one is board certified in interventional radiology and diagnostic radiology and is actively practicing. Reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. Reviewer number three is board certified in general surgery with expertise in interventional radiology and is 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for custom made shoe inserts/foot orthotics for treatment of the enrollees congenital abnormality of the lower limb. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested custom made shoe inserts/foot orthotics. A review of the published literature does not support the benefit of orthotics for treatment of the patients flat foot deformity with associated tibial varum and internal tibial torsion. There is a lack of support in the peer-reviewed literature demonstrating that orthotics are more effective than standard therapy for the treatment of the patients medical condition. Final Result: The reviewers determined that the requested equipment 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 podiatry 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 51-year-old male enrollee has requested for the prescription medication Boniva for treatment of his low bone density.    Findings:  The physician reviewer found that although the Food and Drug Administration (FDA) approved indication for Boniva is for postmenopausal osteoporosis, this does not mean that it would be ineffective in treating men with osteoporosis.  Other biphosphates have indications for treatment in both men and women.  There are studies documenting the effective use of Boniva in men as well as women.
Appeal type: Experimental/Investigational
Decision: Overturned

A 39-year-old female enrollee has requested for hepatectomy (resection of liver and partial lobectomy) for treatment of her recurrent metastatic ovarian cancer. Findings:  Two physician reviewers found that the most important predictor is complete removal of disease. This patient is likely to benefit from liver-directed surgery as well as resection of the left lower quadrant mass. The concept of tumor debulking is well-established and associated with prolonged survival. It is unlikely that further chemotherapy would provide similar benefit. Current CT scans suggest that the recurrent cancer is amenable to surgical debulking.