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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma gene assay. Findings:  Three physician reviewers found The prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add to these statistics. DecisionDx-Melanoma gene assay is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the risk of metastasis. Studies reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma gene assay classification in patients undergoing sentinel node biopsy. It is not clear how the five-year data from DecisionDx-Melanoma gene assay compares to the ten-year Balch data. Most importantly, it is not clear whether clinical decisions can be made on the basis of DecisionDx-Melanoma gene assay classification. Therefore, the superior efficacy of DecisionDx-Melanoma gene assay has not been established. 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 reviewers 1, 2 and 3 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: Medical Necessity
Decision: Overturned

The patient has requested reimbursement for modafinil 200 mg (90 tablets/30 day supply). There are several studies demonstrating the benefit of modafinil for patients with ADHD. The researchers reported that modafinil was associated with improved short-term memory, visual memory, spatial planning, and stop-signal motor inhibition in adult patients with ADHD. This patient has a diagnosis of ADHD, but his symptoms have been stable with modafinil. Without modafinil, the patient poses a risk of decompensation. Moreover, the patient previously failed treatment with traditional stimulant medications for ADHD. The records documented that the medication dosage at issue is safe and effective in this patients case, as this dosage has been well tolerated for several years by this patient. Given patients stability, failure of previous treatment options, and clinical evidence that ADHD demonstrates benefit, the modafinil 200 mg (90 tablets/30 day supply) was medically necessary for treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 psychiatry with subspecialty certification in geriatric 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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Aimovig auto-injectors. The enrollee has a history of chronic migraines. She has had recurrent headaches for 12 years. The enrollee reports headache durations of one to two days, and they are associated with nausea, vomiting, auras, and photophobia. A computed tomography scan of the head was negative. She has tried Topamax, but experienced cognitive problems. She has also tried nortriptyline, sumatriptan, rizatriptan, baclofen, and dicyclomine. She is requesting coverage for Aimovig injections for migraines. Medical records show the enrollee tried and failed Topamax and nortriptyline, which is nearly identical to amitriptyline, along with other medications approved governmental bodies for migraine headache.  Literature reports Aimovig is effective for migraine prophylaxis and is approved by governmental bodies for this purpose.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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for durable medical equipment (DME) (wearable cardioverter defibrillator). Findings:  The physician reviewer found that American College of Cardiology (ACC) and American Heart Association (AHA) guideline for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death noted that an alternative to an implantable cardioverter-defibrillator (ICD) is the wearable cardioverter-defibrillator. The guideline found that wearable cardioverter-defibrillators were appropriate in patients with ventricular fibrillation. In this case, a cardiac catheterization demonstrated complete right coronary artery occlusion, and an echocardiogram report reported cardiac wall hypokinesis. Electrocardiograms (EKGs) demonstrated ventricular tachycardia that required defibrillation and new left bundle branch block which reversed on subsequent EKGs.  In this clinical setting, the risk of sudden cardiac death (SCD) is significant and the LifeVest was appropriate. Therefore, the durable medical equipment (DME) (wearable cardioverter defibrillator) was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the durable medical equipment (DME) (wearable cardioverter defibrillator) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested device was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested methadone and Fentanyl patches for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that in this clinical setting, the recommendation to taper the patients pain medications are well supported by the medical literature. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting (Raffa, et al).  Moreover, the submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. In addition, the submitted documentation does not indicate an optimization of all non-opioid medications (Mendlik and Uritsky). Rather, quite large doses of opioids are being used without a clear rationale for such a high dose despite research to show its dangers. In this patients case, tolerance has taken place since the start of the narcotics. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The addition of more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation. However, studies have shown that down regulation will transpire and then the patient is only back to where they started in terms of their pain perception. Patients are worse off since they now have a much higher opioid tolerance level. There is also the possibility of opioid induced hyperalgesia. Finally, the requested medications are not considered evidence based treatments for fibromyalgia. Physical exercise should be considered another treatment option over opioids. Therefore, the recommendation to taper the patients pain medications is medically appropriate.  For all these reasons, methadone 10 mg (up to 6 tablets as needed) and Fentanyl patches 100 mcg (2 patches every 48 hours) are not medically necessary for treatment of the enrollees medical condition.Final Result: The reviewer determined that the requested medications 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pulsed dye laser treatment to the left lower lip. The submitted documentation fails to demonstrate the medical necessity of the requested services. The medical records indicate that the lesion has been asymptomatic and has not bled. Therefore, the requested pulsed dye laser treatment to the left lower lip is not medically necessary. An angioma is not considered to be an abnormal structure of the body. The lesion is not causing any functional impairment, and the requested services will only provide a minimal improvement in the appearance of the patient. Therefore, the requested services are not reconstructive in nature. In sum, the requested pulsed dye laser treatment to the left lower lip is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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: Overturned

The patient has requested reimbursement for ThyGeNEXT and ThyraMIR genetic testing of thyroid nodules provided by Interpace Diagnostics. Per the American Thyroid Association (ATA) guidelines, patients with thyroid nodules with atypia of undetermined significance (AUS) or FLUS cytology, repeat fine needle aspiration (FNA) or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Researchers reported that high sensitivity and specificity are obtained using the combination testing of ThyGeNEXT and ThyraMIR as demonstrated in two different studies that combined these tests for indeterminate thyroid nodules. The records provided for review document that the results of the genetic test were critical to determine whether to perform a total thyroidectomy versus observation. As this patient had a thyroid nodule with FLUS pathology results, the genetic testing was indicated to help establish whether the patients tumor was malignant and guide treatment decisions. All told, the ThyGeNEXT and ThyraMIR genetic testing of thyroid nodules provided by Interpace Diagnostics was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in diabetes, 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: Overturned

The parent of a 13-year-old female enrollee requested licensed vocational nurse services for 14 hours per day during the week and 8 hours per day on the weekends for medical treatment of the enrollees ataxia, moderate intellectual disability and seizure disorder.  Findings:  The physician reviewer found that in order to provide a safe and secure environment, including medication administration, recognition of distress, and prevention of complications, the requested services are medically necessary.  Although her mother is a trained caregiver, the patient is now the size of an adult and requires two adults to move her, bathe her, and transport her.  This patient requires monitoring of seizure activity, medication administration, and gastrostomy tube feedings.  The services of a licensed vocational nurse are needed to identify subtle seizure activity or signs of aspiration.  All told, licensed vocational nurse services for 14 hours per day during the week and 8 hours per day on the weekends are medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

This patient is a 50-year-old female with a history of Hepatitis C, genotype 3a.  She was treated with a six-month course of Pegasys and ribavirin. The patients last PCR level was 223 in November of 2005. She has requested authorization for an additional six months of Pegasys and ribavirin therapy.  The Health Plan determined the requested therapy is not medically necessary, and denied her request.The record provided is somewhat limited with respect to past medical history.  The value of the initial quantitative PCR is not clear from the reports submitted, however the norm is to discontinue therapy if there is not a 2-log drop within the first three months of treatment.  This patient completed six months of therapy. Although some investigators continue treatment up to 48 weeks in genotype 3, it is not the standard of care and is not FDA approved. Based upon the information set forth above, I have determined the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ampyra 10 mg. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Ampyra is indicated for patients diagnosed with multiple sclerosis. There is a lack of sufficient peer-reviewed literature supporting Ampyra for the treatment of patients with hereditary spastic paraplegia. A study included 12 patients and reported encouraging results. Another study included five patients and showed improvement in gait speed. In addition, to the small sample population, there is a lack of placebo controlled trials supporting Amprya in this clinical setting. Therefore, Ampyra 10 mg has not been established as medically necessary in this clinical setting.  Final Result: The 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: Physician reviewer number one 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:The patient has requested reimbursement for air and associated ground ambulance transportation services. Acute transverse myelitis can cause profound functional impairments, including loss of limb function and loss of bladder and bowel control. Once diagnosed, treatment with immunotherapy, starting with steroids, is warranted to halt the inflammatory process, allowing recovery to commence. Plasmapheresis, aimed at removing humoral factors inciting the myelitis, is warranted when the response to steroids is poor. Recovery from acute transverse myelitis can be protracted and approximately two-thirds of patients sustain moderate to severe degrees of residual disability. Rehabilitation is typically indicated to optimize function in light of the impairments and to mitigate risk of complications, such as pressure injuries and infections. The records provided for review document that this patient sustained acute paraplegia with neurogenic bladder and bowel due to an idiopathic transverse myelitis. He was hospitalized in California, where he received emergency and acute hospital care services. He was medically stabilized and ready for transition to a rehabilitation facility as of late April 2020. Due to the severity and complexity of his deficits and medical needs, as well as the intensity of his rehabilitative needs, he required acute inpatient rehabilitation services. However, the records do not demonstrate that the patient required transfer from California to Illinois for rehabilitation, or that such transfer required ground and air ambulance services. The facility in Chicago was not the closest facility that could have provided appropriate care for the patient. There are multiple appropriate facilities in the northern California area. Notably, San Francisco, which is a major U.S. metropolitan area with multiple major medical and rehabilitation centers, is in close proximity to Folsom, and within the range of ground ambulance transportation. Transfer to an acute inpatient rehabilitation facility in the state of Illinois, instead of in the patients home state of California, was not consistent with current medical literature recommendations. For these reasons, the air and associated ground ambulance transportation services were not medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

The patient is a 52-year-old male with chronic back pain who is requesting a bariatric adjustable bed. He states that he has tried physical therapy and epidural injections without benefit and that he can no longer sleep in a standard bed. His Health Plan has denied authorization for the requested equipment.From an orthopedic standpoint the requested equipment is not medically necessary or required to treat the patients condition. There are no long-term, prospective studies showing that there is any benefit in the use of a bariatric adjustable bed in the treatment of back pain. There is a great deal of variability with beds and their potential effectiveness is based entirely on patient preference. There simply is no evidence supporting the medical necessity of the requested equipment. Therefore, the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 35-year-old female enrollee has requested for revision of gastric bypass to a duodenal switch for treatment her condition.   Findings:  Two physician reviewers found that revisional surgery is associated with two to four times the incidence of anastomotic leak and twice the incidence of wound infection and other major morbidity. Revisional surgery has also been associated with increased mortality. This is because the operations are often complicated by the presence of adhesions or patients may still be morbidly obese or tissue perfusion may not be optimal, which can all inevitably affect anastomotic healing.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old female enrollee has requested rituximab for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the patient has a progressive form of multiple sclerosis with ongoing active inflammatory disease as demonstrated by gadolinium enhancing and new T2 lesions on recent MRI. This patient should be on active multiple sclerosis therapy. Rituximab is a therapy used to treat relapsing forms of multiple sclerosis and has been shown to be effective. This patient requires ongoing therapy for her multiple sclerosis. Rituximab is a medically appropriate option for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested for the Pillar procedure for treatment of his obstructive sleep apnea.   Findings:  Three physician reviewers found that there are only a few articles available regarding the Pillar palate implant procedure. There are no long-term studies available. This procedure is primarily suitable to treat snoring and mild to moderate sleep apnea. Even in these cases, the results show that less than half the patients studied experience improvement. The Pillar procedure in conjunction with other procedures may be of benefit in some cases.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested 17 acupuncture visits for treatment of her chronic back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The clinical notes provided document only temporary relief from the acupuncture treatment.  Although the peer-reviewed literature supports an acupuncture trial, there should be documentation of objective, measurable improvement in order to support additional care beyond the initial course.  In this patients case, there was a lack of progression in function.  All told, 17 acupuncture visits provided during the said timeframe were not medically indicated, and continued weekly acupuncture visits are not medically necessary for the treatment of this patient.