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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hizentra 13 gram subcutaneous infusion (CPT code J1559) administered at an ambulatory infusion center every week.The submitted documentation supports that the requested medication is medically necessary. Researchers note that human immunoglobulin preparations for intravenous or subcutaneous administration are the cornerstone of treatment in patients with primary immunodeficiency diseases affecting the humoral immune system. In this case, the patients laboratory data support the diagnosis of specific antibody deficiency. In 2017, the patients pneumococcal antibody titers were only positive for 4 out of 14 antibody titers and did not improve upon vaccination with pneumovax and rechecking the values four weeks after vaccination. This testing confirms the patients diagnosis of specific antibody deficiency, in the setting of recurrent sinopulmonary infections. Under these circumstances, immunoglobulin replacement therapy is an appropriate and medically necessary treatment for the patient. Accordingly, Hizentra 13 gram subcutaneous infusion (CPT code J1559) administered at an ambulatory infusion center every week is medically necessary for the 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 both internal medicine and allergy and immunology, 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 digital breast tomosynthesis for the enrollees breast cancer screening. Findings:  The physician reviewers found that the patient had a digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population.   The digital breast tomosynthesis was likely to be more beneficial for this patient than other available standard modalities. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: Two of three reviewers determined that the service 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: Physician reviewers number one, two, and three are board certified in diagnostic and 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that the medical literature supports breast tomosynthesis in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers when compared to two-dimensional imaging alone.  Thus the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: 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 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for nasal surgery for treatment of the enrollee, who was status post septorhinoplasty. Findings:  The physician reviewer found that this patients case, there is well-documented evidence of nasal breathing problems from a previous septorhinoplasty. Her symptoms, clinical examination findings and photographs are consistent with partial nasal obstruction. The operative report is consistent with the preoperative plan for correction of functional impairment. There was evidence of internal and external nasal valve collapse, as well as septal deviation and septal spine dislocation. The records document clinically significant nasal obstruction from a predictable pattern of deformity and impairment. Rhinoplasty with septoplasty would be consistent with standard of care in the setting of residual nasal deformity and nasal airway obstruction as a result of her condition.  All told, nasal surgery performed was medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 plastic 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: Experimental/Investigational
Decision: Overturned

A 28-year-old female enrollee has requested Botox injection therapy for treatment of her migraine headaches.  Findings:  Two physician reviewers found that the patient has been diagnosed with chronic migraine, and tried and failed prior preventives. To date, the use of Botox for treatment of patients with chronic migraine has been evaluated in phase 3 studies. The patients were treated with 155-195 Units and showed definitive statistical and clinical benefits in terms of reduction in of headache days in comparison to placebo. A responder rate of nearly 70% was seen in Botox treated patients. This is a higher responder rate than is seen in management of episodic migraine with standard oral preventives (typically about 50%), suggesting that Botox may in fact be more effective than standard preventives even in patients who have not tried and failed standard therapies. Thus, there is adequate evidence that Botox is more beneficial than placebo, and is clinically beneficial in the majority of patients. Moreover, based on 2 phase 3 trials, the Food and Drug Administration (FDA) has approved Botox as a chronic migraine preventive therapy, at dosing of 155 Units. Of import is that there are no other FDA approved medications for chronic migraine. As Botox is FDA approved for the indication of chronic migraine, it is not experimental. Therefore, Botox should be approved as per FDA indication.
Appeal type: Medical Necessity
Decision: Upheld

A 51-year-old female enrollee requested physical therapy for medical treatment of his adhesive capsulitis.  Findings:  The physician reviewer found that the patient appears to have participated in an adequate trial of physical therapy with 15 sessions, but the only evidence of improvement is subjective reports of decreased pain. Therefore, the patient should have been able to transition into a home exercise program for continued exercises. Consistent with these findings, additional  physical therapy services were not medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Xifaxan 200 mg tablets. The U.S. Food and Drug Administration (FDA) approves the use of Xifaxan for the treatment of travelers diarrhea, reduction of risk of overt hepatic encephalopathy recurrence, and irritable bowel syndrome with diarrhea. Current medical literature and guidelines on the treatment of chronic obstructive pulmonary disease (COPD) do not support the use of Xifaxan in the treatment of COPD. In this clinical setting, the medication at issue was not medically indicated. Therefore, Xifaxan 200 mg tablets were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was 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 internal medicine with sub-specialty certifications in pulmonary disease and in critical care 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: Overturned

The parent of a 19-year-old female enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that applied behavior analysis (ABA) is an empirically proven treatment intervention for children, adolescents and adults with autistic disorder. Granpeesheh, et al. stated that, ABA has also been demonstrated to be effective in addressing particular challenging behaviors and skill deficits in older children and adolescents. Accordingly, based on the clinical presentation and literature review, a course of the requested therapy was medically necessary for treatment of the patients medical condition. As such, there is insufficient evidence that continued therapy beyond a three-month treatment course is medically necessary. Therefore, based on the documentation provided, three months of ABA treatment, was medically necessary.
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 risk for breast cancer. Findings:  2/3 of the physician reviewers found that in the peer-reviewed medical literature, colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: 2/3 of the 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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: Upheld

The parent of a 15-year-old female enrollee has requested coverage for Nexavar 400mg twice a day with Temodar for treatment of the enrollees metastatic melanoma. Findings:  Two physician reviewers found that review of the medical literature for the treatment of aggressive PNST as well as sarcoma, the two more common categories from which data and decision-making may be extrapolated reveals insufficient evidence to support the proposed regimen. The literature from malignant melanoma is not as relevant, as the patients tumor is melanotic/pigmented, but has not been classified as malignant melanoma, which is distinct biologically, histologically, and immunophenotypically from the diagnosis indicated in the pathology report.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested genetic testing (CPT 81225, 81226, 81227 and 81479) for medical evaluation of her myalgia.  Findings:  Three physician reviewers found that genotype testing was not appropriate or clinically indicated for the patients chronic condition as it does not demonstrate contribution towards improving or adding to treatment of the patients condition. Jannetto and Bratanow performed a study to evaluate the clinical effectiveness of genotyping chronic pain patients on analgesic therapy. The authors found a positive association between the geneotypes of chronic pain patients and adverse reactions to opioid therapy; however, the results were not statistically significant. Finally, the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. For the reasons provided, the testing at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The enrollee is requesting authorization and coverage for air ambulance transfer. The enrollee experienced a hemorrhagic stroke while on vacation. He was taken to the hospital and underwent a decompressive craniectomy with placement of a drain. He was taken off the ventilator the next day and a computed tomography of the head showed no further bleeding or swelling. He was transferred by air ambulance to a neurological institute for further management. A letter from the treating physician indicates the enrollee had dense left-sided hemiparesis and significant deficits, with an extensive need for continuing, specialized medical care. The records show the enrollee had a large right parietal brain bleed. He also experienced left-sided paralysis after the bleed. Though his computed tomography angiogram was normal, a subarachnoid hemorrhage due to an aneurysm remains likely. An angiogram and management by a neuro-intensivist in an intensive care unit setting was essential; this is supported by literature, which shows individuals who experience a brain bleed require specialized care by neurologists.  There was no report of any neurologists on staff at the treating hospital and thus the treating hospital was not equipped to provide the necessary care for this enrollee.  Transfer to a neurological intensive care unit was medically necessary.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition.  Credentials/Qualifications: The physician reviewer is board certified in neurology 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 53-year-old male enrollee requested intensity modulated radiation therapy (IMRT) for medical treatment of his scalp cutaneous follicular cell non-Hodgkins lymphoma stage T2N0M0.  Findings:  Two physician reviewers found that the complexity of treating scalp lesions is based upon the changing surface contours in two planes as well as the underlying brain and adjacent critical structures such the eyes and lacrimal glands. While the dose delivered in this patient was 30 Gy, which is deemed to minimize risk of late complications, the issue of potentially matching electron fields may lead to under treatment of the target or overlap leading to hot spots. In this clinical setting, IMRT provides a solution to the changing contour of the scalp thereby limiting match lines and the risk of overlap. Given these findings, the use of IMRT was likely to have been more beneficial for treatment of this patients cutaneous follicular cell non-Hodgkins lymphoma than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 56-year-old male enrollee has requested for Nexium for treatment of her gastroesophageal reflux disease (GERD).  Findings:  The physician reviewer found that the patient has tried Prevacid, Protonix and Prilosec for one month and has had no response. The Health Plan requires formulary medications to be tried for 8 weeks prior to authorization and coverage for Nexium. This is a medically reasonable requirement that has not been documented in the provided records.
Appeal type: Medical Necessity
Decision: Upheld

A 62-year-old female has requested coverage for past and future skilled nursing services and/or skilled nursing facility (SNF) rehabilitation services for treatment of her medical condition status post right front parietal stroke.   Findings:  The physician reviewer found that the patients records indicate that by the date under review, she required stand by assistance for ambulation and ambulating 100 feet with a walker. The progress notes do not document that she progressed beyond this level with continued therapy and actually showed evidence of some regression. Consistent with the medical literature the skilled services provided from the date under review and forward are not medically necessary to establish a maintenance program or to prevent deterioration of the patients condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 50-year-old female enrollee requested hormone pellet implantation and continued hormone pellet implantation every three to four months for medical treatment of her medical condition.  Findings:  Two physician reviewers found that Vestibulodynia is typically a multifactor disease, and is conventionally treated with a combination of vulvar care measures, topical, oral and injectable medications, biofeedback, physical therapy, sexual counseling and, as a last resort, surgery.  Testosterone pellet implantation is not a recommended therapy at this time.  The current medical evidence does not support the requested hormone pellet implantation in this patients case.  The risks of testosterone therapy include acne, liver dysfunction, hirsutism and adverse lipid changes.  There is insufficient scientific evidence supporting the safety and efficacy of testosterone therapy in this setting. Therefore, hormone pellet implantation and continued hormone pellet implantation every three to four months is not likely to be more effective than other treatment alternatives.
Appeal type: Urgent Care
Decision: Upheld

A 41-year-old female enrollee requested emergency services provided on an emergent basis.  Findings:  The physician reviewer found that review of the submitted documentation indicates that the patient decided to seek emergency treatment due to recent high fever and development of fever blisters. Upon presentation to the Emergency Department, the patient did not have a fever. Her vital signs were normal and she had no evidence of respiratory distress, shortness of breath or chest pain. The rash was described as non-painful. All told, there is no evidence that the patient was experiencing signs and symptoms that would cause a prudent layperson to believe her health was in serious jeopardy without immediate medical attention. The patients symptoms did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

A female enrollee requested laser therapy for medical treatment of her vitiligo.  Findings:  The physician reviewer found that this patient has a history of vitiligo which has been unresponsive to topical therapies.  Based upon the submitted records, the requested laser therapy is medically necessary for the treatment of this patient.  In this patients case, her condition is abnormal pigmentation related to destruction of melanocytes in the skin.  The abnormality is cause by an autoimmune, immunologic process.  The requested procedure should correct the pigmentary abnormality, restoring the skins natural defense (pigmentation) against ultraviolet-induced skin cancers.  All told, the requested laser therapy is reconstructive in nature and is medically necessary for the treatment of this patient.