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

A 60-year-old female enrollee has requested an Oncotype DX tumor assay for evaluation of her breast cancer.  Findings:  Three physician reviewers found that Oncotype DX tumor assay predicts quite accurately the risk of distant recurrence of the cancer by 10 years if the patient is treated with hormonal therapy as the sole systemic treatment. There is good literature support for its reliability. The assay has been shown to be valid only in node-negative, estrogen receptor positive tumors. It has become very important, particularly in this group of breast cancer patients in which it is very difficult to make recommendations about adding adjuvant chemotherapy.  Based on the accumulating data suggesting its validity in predicting risk, the Oncotype DX tumor assay has found its way into the clinic and more oncologists are relying on the recurrence score to make adjuvant treatment recommendations as to who should get and (more importantly) who may not need chemotherapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a nine-year-old male has requested speech therapy with ongoing speech evaluation and occupational therapy for treatment of his autism. Findings:  The physician reviewer found that the report by Myers, et al. is frequently cited in the autistic literature as a definitive source for the evaluation and treatment of autistic children. It is concluded in this report that, people with autism spectrum disorders (ASDs) have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate.  Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services (Myers, et al.). In a controlled study comparing autistic children who did and did not receive speech therapy, those who received therapy had far greater communication skills than children who did not receive speech therapy (Turner, et al.). The Speech and Language Association also states that autistic children can benefit from speech therapy. The medical literature supports both occupational therapy and speech therapy in the autistic population. Occupational therapy utilizing sensory integration techniques is an efficacious therapy for reducing many of the unwanted mannerisms associated with autism (Pfeiffer, et al.). May-Benson and Koomar performed a meta-analysis of 27 journal articles utilizing sensory integration techniques for autistic children and concluded that sensory integration was effective. All told, there is ample literature support for the use of occupational therapy in the treatment of children with autism.
Appeal type: Medical Necessity
Decision: Upheld

A 70-year-old female enrollee has requested for in-home physical therapy for treatment of her post amputation. Findings:  The physician reviewer found that the lack of progress from prior therapy. In order for therapy to be medically necessary, there must be evidence of progression or improvement for the services to be continued.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CPT codes including, 64568 - incision for implantation of cranial nerve (eg. vagus nerve) neurostimulator electrode array and pulse generator; and 61885 - insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array. Findings:  Three physician reviewers found that the medical literature, VNS sends electric pulses to the left vagus nerve every few seconds and it is hypothesized that the subsequent modulation of certain neural tracts enhances serotonergic and noradrenergic innervation and possibly increases blood flow to critical brain structures which in turn alleviates clinical depression. In this case, the patient is diagnosed with bipolar disorder which is a highly-recurrent, lifelong and disabling mental illness. Her affective illness is consistent with treatment resistant depression. The patient has exhausted U.S. Food and Drug Administration approved treatments for bipolar depression. She has also trialed many off-label pharmacotherapies along with a course of electroconvulsive therapy. The VNS device was originally implanted in 2007. Such devices have an approximate duration of operability ranging from 6 to 11 years. Thus, the need for replacement at this time is not unexpected. The treatment has been well-tolerated for the past nine years. In addition, the treatment is recommended by the patients treating psychiatrist. Final Result: Three reviewers determined that the requested services are 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: All three physician reviewers are board certified in psychiatry 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

The parent of a 4-year-old male enrollee has requested for occupational and physical therapy services for treatment of the enrollees autism.  Findings:  Three physician reviewers found that tt is through their sensory experience that children develop connectedness with the world. When children show sensory dysfunction, it is harder for them to interact and learn about the world. These children are then less able to successfully participate in and develop the occupations of childhood, such as play, social interaction, and learning. Children with ASD (autism spectrum disorder) have a range of occupational and performance problems that interfere with their full participation in school, home, and community activities. Predominant characteristics of autism that are often the focus of intervention include limited social interaction, delayed or deficit language, behavioral problems, and sensory-processing difficulties.Generated by an occupational therapist and developed primarily within the profession of occupational therapy, sensory integration theory and its application provide an important set of knowledge and skills for practitioners. Sensory integration is also one of the first theories generated within occupational therapy to undergo the rigor of providing evidence that validates its constructs while providing direction for the strategies clinicians use to remediate the underlying sensory issues that affect performance. Research demonstrating the efficacy of sensory integration treatment based on sensory integration theory has been published. Its theories provide a framework from which occupational therapists can generate treatment plans for children with sensory integration disorders that will allow them to successfully participate in the occupations of childhood.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomography (CT) scan of the heart, without contrast, with qualitative evaluation of coronary calcium. Coronary artery calcium measured by cardiac CT can help provide an estimate of total coronary plaque burden and is an established tool for cardiovascular risk stratification and preventive therapy. Several guidelines have recommended the use of coronary artery calcium testing in shared decision making between the provider and patient. However, the American College of Cardiology (ACC) and American Heart Association (AHA) guidelines do not recommend coronary artery calcium for further evaluation of patients with ventricular tachycardia (Al-Khatib, et al.). Per the AHA/ACC guidelines, echocardiogram has a class 1 recommendation while cardiac CT or magnetic resonance imaging (MRI) have class 2A recommendations for the evaluation of cardiac structure and function in this clinical setting (Al-Khatib, et al.). The European Society of Cardiology (ESC) guidelines recommend echocardiography and exercise stress testing as Class 1 recommendations and cardiac MRI and cardiac CT as Class 2 recommendations in screening patients with documented or suspected ventricular arrhythmias (Priori, et al.). This patient was noted to have an elevated 10-year risk for atherosclerotic cardiovascular disease. Overall, there is a lack of data to support an indication for coronary artery calcium as a useful tool in this patient as a part of his work-up for ventricular tachycardia. Accordingly, the CT scan of the heart, without contrast, with qualitative evaluation of coronary calcium was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in cardiology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 3 is board certified in interventional cardiology 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

A 58-year-old female enrollee has requested Byetta for the treatment of her type 2 diabetes mellitus. Findings:  The physician reviewer found that whether Byetta has replaced the patients insulin or the patient is treated with a combination of Byetta and insulin is immaterial. In either event Byetta is not medically indicated. There is no evidence demonstrating that the patient requires the addition of Byetta to her treatment regimen. Without such evidence Byetta cannot be considered medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for bilateral mastectomies. Catanzariti and colleagues noted that, ADH [atypical ductal hyperplasia] is one of the most common B3 lesions of the breast and the one with the highest risk of malignant transformation. It is therefore considered a non-obligate precursor of invasive cancer as well as an independent risk factor for breast cancer. The authors commented that, ADH is associated with a higher risk of invasive breast cancer, four to five times higher compared with the normal population. Racz and colleagues noted that, Histologically, ADH and low-grade DCIS [ductal carcinoma in situ] are virtually identical. Amersi and Calhoun reported that the final decision-making regarding prophylactic mastectomy depends on a womans long-term absolute risk, the current age and anticipated residual risk, the risks of prevention medication versus risks of surgery, the degree of risk reduction anticipated from each approach, and the patients preferences and values. While bilateral prophylactic mastectomy is not the treatment of choice for ADH, this patient has had both DCIS and ADH excised from breasts. The records document that the patient has undergone multiple interventions, and is concerned that another breast cancer will develop. The patient complains of severe disabling pain from most recent wide lumpectomy, as well as pain from the scar tissue from past lumpectomies in the other breast. Given these findings, the requested bilateral mastectomies are medically necessary for 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 49-year-old female enrollee requested gene testing (BRAF mutation analysis, CPT code 81210 and KRAS mutation analysis, CPT code 81275) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that in this patients case, the services at issue were likely to have been of greater benefit than other methods of evaluation.  Molecular testing has been developed which utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy.  Because the testing is very sensitive and has a high negative predictive value, a negative result is suggestive of a benign nodule and can therefore preclude surgical procedures.  All told, gene testing (BRAF mutation analysis, CPT code 81210 and KRAS mutation analysis, CPT code 81275) was likely to have been more efficacious than other options for evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued physical therapy, three times per week with an emphasis on balance and proprioception. Findings:  The physician reviewer found that There is sufficient support in the medical literature for the requested services in this clinical setting.  The medical records indicate that the request at this time is for additional physical therapy with an emphasis on balance and proprioception. This patient fractured the distal tibiofibular joint in spring of 2017. The records note that the patient required surgery to strengthen her ankle. The provider noted without a walker, the patients gait was less steady and the patient took shorter strides. The left ankle dorsiflexion was prone, 5 degrees. The provider noted that the patients gait with the walker was less steady and she was only able to take shorter strides.  The patients gait with a quad cane was slow and the patient was still unsteady. The left ankle dorsiflexion was prone, 5 degrees. The patient is participating in physical therapy but based on the records, she has made slow progress in a land based therapy. The standard of care, in this clinical setting, supports physical therapy three times per week. The patient states she continues to have functional limitations, as balance is an issue. Physical therapy once per week would be insufficient for a patient who is not yet independent. Additionally, physical therapy with an emphasis on balance and proprioception is also supported in this patients case. Aquatic therapy is a treatment option that is well supported in the medical literature as an alternative form of treatment to address limitations of land based therapy. There are some risks involved with land based gait/proprioception training such as falling during training.  For these reasons, continued physical therapy, three times per week with an emphasis on balance and proprioception is medically necessary for treatment of this patient at this time.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 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: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Hetlioz (tasimelteon) 20 mg. The U.S. Food and Drug Administration (FDA) approves the use of Hetlioz (tasimelteon) for the treatment of non-24. A study describes non-24 as a circadian rhythm disorder, occurring most commonly in blind individuals without light perception, characterized by a persistent cycle of nighttime insomnia and daytime sleepiness. The study notes clinical trials in healthy individuals confirmed the circadian phase-shifting potential of tasimelteon, and that safety assessments indicated that tasimelteon is well tolerated. In this case, the patient has a diagnosis of non-24 and has tried and failed several medications. The provider recommended continuing Hetlioz based on the patients clinical response during an initial trial of the medication. Given the patients diagnosis and the providers recommendation, the requested medication is medically indicated. Therefore, Hetlioz (tasimelteon) 20 mg is medically necessary for the treatment of this patient. 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 sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Accu-Check Smartview test strips for the evaluation the enrollees blood sugar levels. Findings:  The physician reviewer found that the medical literature does not support the medical necessity of the requested test strips in this clinical setting. The patient requested the Accu-Check Smartview strips because she believes they are safer to use around her son. However, the records do not demonstrate that this patient presents with any medical or physical deficits which preclude her from using other meters to test her blood sugar levels. There are other types of glucose meters available to this patient. Precautions can be taken to maintain the safety of the patient and her family. Therefore, the requested Accu-Check Smartview test strips are not medically necessary for the evaluation of this patients blood sugar levels. Final Result: The reviewer determined that the requested supplies are 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 internal medicine with sub-specialty certification in endocrinology and metabolism 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 Harvoni for eight weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the national American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines give both Harvoni and Viekira Pak (with or without ribavirin) the same class recommendation, which implies that both are equivalent. In addition, both Viekira Pak (with or without ribavirin) and Harvoni have the same efficacy and relatively low and mostly minor adverse side effects. There is a lack of evidence in the documentation submitted for review showing that this patient has a contraindication to ribavirin. Therefore, although this patient should be treated for chronic HCV, there is a lack of data demonstrating the patient has a contraindication with Viekira Pak which has been authorized by the Health Plan. As such, the requested medication is not medically necessary in this clinical setting. Final Result: Two reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested anesthesia services provided during a colonoscopy for evaluation of her risk for colon cancer.  The physician reviewer found that the anesthesia services for colonoscopy were not medically necessary. Administration of general or regional anesthesia is considered medically necessary when the services are provided by a provider other than the provider performing the procedure and alternative types of anesthesia, sedation, or analgesia are not appropriate. A clinical document indicates that this patient has acid reflux and hypothyroidism. The patient was noted to have complained of abdominal pain and swelling and heartburn. The physical examination revealed normal consistency, no tenderness or masses, and normal bowel sounds of the abdomen and normal, nonpalpable of the liver and spleen. There was no documentation with evidence of prolonged or therapeutic endoscopic procedure requiring deep sedation, a history of or anticipated poor response due to intolerance, increased risk for complication due to comorbidity, evidence of pregnancy, or history of drug or alcohol abuse. There was also no documentation with evidence the patient was uncooperative or agitated during the procedure. For these reasons, the use of anesthesia during colonoscopy is not supported as medically necessary for evaluation of this 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.