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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Zio Patch. Based on the records provided for review, this patient presented with complaints of intermittent heart pounding and palpitations. For evaluation for dysrhythmia, serial 48-hour Holter monitoring, offline self-activated, or auto-triggered cardiac event monitoring would be sufficient first steps in recording the patients cardiac rhythm during symptoms. There is no documentation to indicate that the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Current expert consensus guidelines endorsed by several national organizations consider patient-activated or auto-triggered event recorders appropriate initial tests and the standard of care for evaluation of dysrhythmias. Continuous real-time monitoring with telemetry services, such as with the Zio Patch, have not been shown to be more helpful than patient-activated or auto-triggered event recorder devices in in this clinical setting. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services such as with the Zio Patch has not been shown to improve health outcomes compared to standard monitoring techniques. Therefore, the Zio Patch was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the Zio Patch was not and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For these reasons, the Health Plans denial should be upheld. Final Result: The reviewers determined that the services at issue were not and are not likely to be more beneficial for treatment of the patient's 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 subspecialty 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested coverage for Guardant 360 Panel Testing for treatment optimization of non-small cell lung cancer status post biopsy.The enrollee was undergoing targeted treatment and was experiencing progression in her disease; therefore, Guardant 360 was performed to determine if there were any additional targeted therapy options available for her disease and to identify if there were any therapy resistant mutations. Findings:  The physician reviewers found that based on a review of existing evidence, there is no clinical indication for the use of whole genome/X home sequencing for cancer. While individual gene or syndrome specific gene panel testing based on established risk assessment and management guidelines may be appropriate, evidence is insufficient, conflicting and demonstrates an incomplete assessment of net benefit versus harm. Additional research has been recommended.  As per the literature only a  handful of genes are of any value in helping select therapy. Although there are scattered reports in the medical literature to suggest some benefits of the test, this is still not the standard of care and the test still needs several studies before any conclusions are made regarding its value. The medical literature has addressed new information in regard to plasma cell-free/circulating tumor DNA testing (liquid biopsy) for genetic alterations. Briefly, the panel indicated cell-free/circulating tumor DNA testing should not be used in lieu of tissue diagnosis.  Standards and guidelines for cell-free DNA/circulating tumor DNA testing for genetic alterations have not been established, there is up to a 30 percent false-negative rate, and alterations can be detected that are not related to the tumor. Cell-free DNA testing can be used in specific circumstances if the patient is not medically fit for invasive tissue sampling or if there is insufficient tissue for molecular analysis and follow-up tissue-based analysis will be done if oncogenic driver is not identified.  Review of the record does not show the enrollee is medically unfit to undergo invasive tissue sampling. Final Result: Three of the three reviewers determined that the requested service is not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Two reviewers are board certified in Hematology and Oncology. One reviewer is board certified in Internal Medicine and Oncology. All 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that there is sufficient support for digital breast tomosynthesis in the evaluation of this patient. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue. The studies have shown that there has been an increased survival rate when tomosynthesis has been used as part of screening mammography. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two dimensional imaging alone. Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely of greater benefit to the patient than had her examination been done using two dimensional imaging alone. 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: Physician reviewers number one, tweo, and three are board certified in diagnostic radiology 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: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested for the prescription medication Lipitor for treatment of his high cholesterol.    Findings:  The physician reviewer found that it does not appear the patient has tried and failed treatment with Zocor, to a dose maximum of 80mg,or had a reasonable trial of Vytorin, with  appropriate dose adjustments.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for mental health residential treatment services rendered for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that : The medical literature supports a portion of the services at issue as medically necessary. Prior to admission into the residential treatment facility, the patient had very serious episodes where she would threaten suicide, cut herself, restrict her food and water intake, and act impulsively. She required residential treatment and DBT treatment. During the period from 1/19/15 through 3/31/15, the patient was at times aggressive, throwing objects, defiant, angry, depressed, and impulsive. Based on the documentation, it was unlikely that the patient could have been treated for her symptoms in a less restrictive environment. However, on 4/1/15, the patient improved enough that she could have been managed in a less restrictive environment. The patient had been utilizing her DBT skills and was expressing herself better and not using alarming terms such as suicidal threats to express her feelings. Her provider felt that she was stable and made no medication changes. Her team also felt that she was improving in the ways she was expressing herself. She was utilizing her toolset to manage her emotions. She continued to have episodes of mood lability, but she no longer required 24 hour supervision. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A forty-nine year-old male with severe onychomycosis of the fingernails and toenails is requesting authorization for Lamisil.  The severity was characterized by pain, bleeding and extensive crumbling. The nails fell off and new nails started growing. Unfortunately, fungus infection returned in the new nails, with severe pain, bleeding and fragility and crumbling of the nails.Reviewers FindingsThe reviewing physician found that submitted clinical evidence shows that this patient has failed treatment with Lamisil and that continued treatment with Lamisil is not likely to be effective.  Therefore, the reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transcranial magnetic stimulation (TMS), including 1 unit of CPT code 90867, 34 units of CPT code 90868, and 1 unit of CPT code 90869. Per the American Psychiatric Association (APA) practice guidelines, repetitive transcranial magnetic stimulation (rTMS) is indicated for patients with major depression who have failed at least one antidepressant medication. In addition, TMS is appropriate for patients who have responded to a prior course of TMS. This patient has ongoing major depressive disorder with suicidal ideation as well as a decline in functioning. He is distressed in all spheres and poses a risk of further decompensation without adequate treatment to alleviate his symptoms. He has failed treatment with CBT as well as multiple psychotropic medications trials in the past due to adverse effects as well as poor treatment response. The records document that the patient attained a significant positive response to TMS in the past. Based on the current APA guidelines, this patient meets the criteria for TMS therapy. Accordingly, the requested TMS including 1 unit of CPT code 90867, 34 units of CPT code 90868, and 1 unit of CPT code 90869 is 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. Credentials/Qualifications: The reviewer is board certified in 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: Upheld

A 38-year-old female enrollee requested authorization and coverage for hypnotherapy. The health plan has denied this request indicating that the requested therapy is not medically necessary for treatment of the enrollees migraine headaches.One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer upheld the health plans denial on the basis that the requested therapy is not medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female has requested coverage for a past inpatient stay for treatment of her major depression, severe, single episode, generalized anxiety disorder, and impulse control disorder, not otherwise specified.  Findings:  The physician reviewer found that although acute hospitalization was appropriate to treat this patient initially, the medical records fail to justify the necessity of inpatient acute care after the second day of the time frame at issue.   The submitted documentation revealed that her atypical antipsychotic medication dosage was increased and, the physician notes the following day described an adherent, clinically stable patient who was tolerating her medications well.  She was not suicidal or gravely disabled due to a mental illness.  The patient had not engaged in any eating disorder behaviors or patterns, and she was active in treatment.  All told, the first two days of the inpatient stay during the time frame at issue were medically indicated.  The medical necessity of inpatient services from that time forward has not been demonstrated.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical fusion surgery for treatment of the enrollees neck pain. Findings:  The physician reviewer found that the request for cervical fusion surgery has not been established as medically necessary for treatment of the patients medical condition. In this case, the patient presents with axial neck pain. She has no symptoms or signs of a cervical radiculopathy or cervical myelopathy. In addition, there is no evidence of failed conservative management. Given the lack of documentation demonstrating cervical radiculopathy, cervical myelopathy and failure of conservative management, cervical fusion surgery is not clinically indicated for this patient. Final Result: The reviewer determined that the requested surgery 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 neurological 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 54-year-old female enrollee has requested an Oncotype DX tumor assay for evaluation of her cancer.  Findings:  Three physician reviewers found that Oncotype DX tumor assay is a 21-gene analysis of breast cancer cells, which produces a recurrence score that 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: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services with an infectious disease specialist for treatment of the enrollees medical condition. Findings:  The physician reviewer found that This patient presents with multiple symptoms and has undergone extensive evaluation. Overall, on physical examination he has no positive findings except for a defect at L5 that may be associated with his complaint of back pain and he is profoundly anxious. However, he has no complaints suggestive of an infectious process. He has not reportedly traveled outside of the U.S. and all of the screening tests for infection have been negative. For these reasons, the requested services with an infectious disease specialist are not medically necessary for evaluation and treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious disease 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

A male enrollee requested platelet rich plasma (PRP) injections for medical treatment of his partial tears of his left supraspinatous tendon and infraspinatous tendon. Findings:  Three physician reviewers found that orthopedic literature indicates that PRP injections are being widely investigated. However, there is a paucity of long-term studies indicating specific efficacy of their use in this clinical setting. There is a lack of studies indicating that PRP injections for this diagnosis are any more beneficial than regular conservative care to include a cortisone injection home exercises, physical therapy and anti-inflammatory medication. For these reasons, PRP injections were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old male has requested Temodar 140mg tablets for treatment of his hemangiopericytoma.  Findings:  Two physician reviewers found that the patient presented one year ago with neurologic symptoms. He was found to have an intracranial mass, and multiple liver lesions. He underwent resection of the brain mass, which revealed a hemangiopericytoma. The patients provider has recommended whole brain radiation to follow surgical resection, and temozolomide (Temodar) for treatment of the systemic disease.The patient has an extremely rare tumor, for which no standard therapy exists.  There are no large scale studies which have been conducted regarding the treatment of this disease, due to its rarity. The best level of evidence available, regarding the treatment of this disease is retrospective case studies. A small study examining 14 patients with hemangiopericytomas reported a significant positive impact of Temodar in the treatment of this disease (Park, et al.). There are no other proven alternatives for the treatment of this disease. In sum, given the results of the small cases series as well as the lack of alternative treatment options in this setting, the use of Temodar is medically appropriate for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 43-year-old male enrollee has requested for platelet-rich plasma injections for treatment of his left Achilles tendon pain. Findings:  Three physician reviewers found that there is a lack of articles with sufficient criteria to validate that platelet-rich plasma injections are an accepted standard of care for treatment of Achilles tendinopathy. The requested services are not likely to be efficacious for treatment of this patients condition than alternative treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 53-year-old female who has requested authorization and coverage for pre-surgical interscalene nerve block of the brachial plexus. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for the patients repeat rotator cuff surgery.Review of the submitted medical documentation indicates the patient is a 53-year-old female who is status post two rotator cuff repair procedures and she is scheduled to undergo a third repair. She is seeking pre-surgical interscalene nerve block of the brachial plexus. The documentation provided indicates the anesthesiologist and orthopedic surgeon feel this procedure will significantly decrease the patients post-operative pain following the procedure. The block will be given in addition to general anesthesia. The literature indicates that a pre-surgical interscalene nerve block allows for improved patient comfort post shoulder surgery and reduced time to discharge. In this particular case, the patient will undergo her third rotator cuff repair and maximal pain control should be instituted to avoid the development of frozen shoulder/chronic pain syndrome. Therefore, I have determined the requested procedure is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested substance use disorder residential treatment for treatment of the enrollees substance use disorder and depression. Findings: The physician reviewer found that the records provided for review document that this patient was not at risk for withdrawals and showed no post-acute withdrawal symptoms. The patient was not a danger to herself or others and she was psychiatrically stable. Her Addisons disease did not require monitoring at the residential level of care. The patient was highly motivated and engaged in treatment. The patient was future oriented as demonstrated by her level of aftercare planning of activities to prevent relapse. She was aware of her triggers and developed insight and coping mechanisms. Her living environment was stable and she had a sober support system in her 12 step group. The patient showed good progress and no longer required treatment in a 24-hour residential setting. All told, the substance abuse residential treatment center services were not medically necessary for treatment of this patients substance use disorder.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 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.