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

Nature of Statutory Criteria/Case Summary: A 53-year-old female enrollee has requested reimbursement for the Guardant360 molecular profiling test using circulating tumor DNA. Guardant360 testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, it has not been determined if molecular markers are useful in treatment determination. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Per the NCCN guidelines for glioblastoma, radiation therapy with temazolomide and alternating electric field therapy is considered the current standard of care. Thus, therapy is not directed by genomic alterations. Accordingly, the Guardant360 molecular profiling test using circulating tumor DNA was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Guardant360 molecular profiling test using circulating tumor DNA was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein for the enrollees medical condition. Findings: Three physician reviewers found that in this clinical setting, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, insulin resistance scoring, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In addition, randomized trials evaluating treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits (Lonne, et al; Toole, et al). Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the advanced lipoprotein testing provided on has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: All three physician reviewers 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

The patient is a 54-year-old male with left-sided prostate nodule on digital rectal examination of 9/9/04 and an elevated PSA of 4.9. Prostate biopsy on 9/14/04 showed benign tissue on the right side. However, on the left side a Gleason score of 3+4 adenocarcinoma was present in 40% of the tissue biopsied. A bone scan performed on 10/8/04 was negative for metabolic disease. Clinically this represents a T2a stage prostate adenocarcinoma, which is potentially curable by surgery. In January 2005, a second urologist reported that in addition to the adenocarcinoma in the left side of the prostate, there was also a Gleason 4+3 adenocarcinoma on the right side of the prostate. The patients urologist has recommended an open radical retropubic prostatectomy. The patient wishes to undergo robotic-assisted laparoscopic radical retropubic prostatectomy. The Health Plan has denied coverage for the requested procedure on the basis it is not medically necessary for treatment of the patients medical condition. Based on Partins Tables, there is a 44% chance of the patients cancer being organ confined. The open surgical approach is a well-established treatment with good long-term results regarding survival and complications. The robotic-assisted laparoscopic procedure is relatively new, and while short-term results are comparable, long-term data especially with regard to survival is not yet available. The procedure offered by the Health Plan is considered standard of care for potentially localized and curable prostate adenocarcinoma, and is medically reasonable and appropriate. Therefore, I have determined that the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Guidelines further state that Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. In this case, the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV genotype 1. Moreover, the requested treatment is expected to prevent further damage of the liver and progression of the disease process and its potential complications. All told, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification 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. that
Appeal type: Medical Necessity
Decision: Overturned

The parent of a four-year-old male has requested  speech therapy for treatment of his autism. Findings:  The physician reviewer found that the literature demonstrates that plasticity in the developing brain exists despite the presence of underlying neurologic disease and speech therapy can be utilized to improve overall neurologic health. Thus, specific treatment, including speech therapy, can be used to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to expressive and receptive speech delay.  Therefore, speech therapy is medically necessary for treatment of the patients severe speech and language delay.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a 60-year-old male enrollee has requested continued skilled nursing facility (SNF) care/rehabilitation services for the treatment of the enrollees multiple medical problems. Findings:  The physician reviewer found that upon admission to Covina Rehabilitation Center, the patient required and received skilled level of care services. His medical conditions were stable, but he required skilled therapies to maximize improvement to his previous level of function. He was not considered a candidate for further treatment (chemotherapy) for his colon cancer condition. He had significant baseline deficits from his mental retardation that were compounded by his psychosis. According to the medical records provided, the patient often did not participate in therapies. The records indicate that therapies were re-initiated and stopped again two days later. During the period at issue, the patient was medically stable, tolerating his oral medication regimen and an oral diet. He had no active wound care issues. There was no documentation indicating he required skilled nursing on a daily basis for medical management issues. By the period at issue, the needs of the patient could have been met at a lower level of care.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 3T magnetic resonance imaging (MRI) of the prostate for evaluation of his localized prostate cancer. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for 3T MRI of the prostate has not been established. According to the American Urological Association (AUA) guidelines for the management of clinically localized prostate cancer an ideal regimen for active surveillance has not been defined but could include periodic repeat prostate biopsies to assess for sampling error of the initial biopsy as well as for subsequent progression of tumor grade and/or volume. The National Comprehensive Cancer Network (NCCN) guidelines include recommendations for prostate biopsy at specific intervals. For active surveillance and observation for individuals with clinically localized prostate cancers who are candidates for definitive treatment, follow-up should include needle biopsy and repeat prostate biopsy if PSA increases. Furthermore, the AUA and NCCN guidelines do not recommend 3T MRI in surveillance protocols. For the reasons provided, the patients request for 3T MRI of the prostate is not medically necessary. Final Result: The reviewer determined that the requested diagnostic procedure is 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 urology 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: A 32-year-old female enrollee has requested authorization and coverage for chiropractic services for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical necessity for chiropractic treatment for the patients condition of Ehlers Danlos syndrome has been established in the medical records provided for review. There is evidence-based literature support for chiropractic treatment for the treatment of Ehlers Danlos syndrome. Specifically, Colloca and Polkinghorn noted that chiropractic care may be of benefit to some patients with connective tissue disorders, including Ehlers Danlos syndrome. Given the support in the medical literature, a clinical trial of six sessions of chiropractic treatment for this patients medical condition is medically necessary. 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 a board certified chiropractor 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 has requested authorization and coverage for breech delivery for treatment of the enrollees fetus in breech presentation.  Findings:  The physician reviewer found that the request for breech delivery is medically necessary for treatment of the patients medical condition. The American College of Obstetricians and Gynecologists Committee Opinion noted that, The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery; Obstetricians should offer and perform external cephalic version whenever possible; Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management; In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented; and Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned. Based on the documentation provided for review, the patient should have the opportunity to have an external cephalic version (ECV) and/or breech vaginal delivery given that records do not demonstrate a contraindication for breech vaginal delivery. For the reasons provided, the requested service is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. FCredentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 41-year-old female enrollee who has requested authorization and coverage for intravenous immunoglobulin (IVIG) therapy. The health plan denied this request indicating that IVIG is considered investigational for treatment of the enrollees history of recurrent pregnancy loss.All three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  Because all three physician reviewers concluded that the requested therapy is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy, the health plans denial has been upheld.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for an Optune device (E0766).  Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved the use of Optune, a portable medical device that produces alternating electrical fields called tumor treatment fields (TTFields), to treat  recurrent glioblastoma. Stupp and colleagues found in an analysis of 315 patients with glioblastoma who had completed standard chemoradiation therapy, that adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. The authors also found that TTFields therapy was associated with lower toxicity and improved quality of life. The National Comprehensive Cancer Network (NCCN) Guidelines for treatment of central nervous system cancers recommend including alternating electric field therapy as adjuvant therapy in combination with concurrent temozolomide and adjuvant temozolomide. In this case, the patient had a diagnosis of glioblastoma, which was progressing. Given the current medical literature, the device at issue was medically indicated. Therefore, an Optune device (E0766) was medically necessary for the treatment of this patient.Final Result: The reviewer determined that the device 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 internal medicine with sub-specialty certification in medical oncology 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: A transgender female enrollee has requested authorization and coverage for facial feminization surgery. Studies show that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. Studies further noted that other surgeries for assisting in body feminization includerhinoplastyfacial bone reduction, face-lift, and blepharoplasty. This patient has a masculine bone structure that is causing gender dysphoria and social dysfunction. A psychological evaluation indicates that patient is depressed from the presence of masculine facial features. The patient has been living as a woman since age 23 and receiving feminizing hormone treatment since that time. The patient is committed to feminine transformation as evidenced by an orchiectomy. The patient meets the criteria for gender dysphoria and indication for facial feminization surgery based upon clinical documentation of persistent gender dysphoria related to masculine facial features associated with social dysfunction. The requested facial feminization surgery is medically necessary to help alleviate the patients gender dysphoria and related distress. Given these findings, the requested facial feminization surgery is supported as medically necessary for treatment of this patients gender dysphoria. 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 with expertise in transgender health 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 forty-six year-old female with chronic myofascial pain syndrome, fibromyalgia, osteoarthritis, migraine headaches, gastritis, and bilateral elbow tendonitis is requesting authorization of Botox therapy.  Reviewers Findings:  Two of the reviewing physicians found that the patient has tried and failed numerous conventional treatment modalities, and has had success with Botox injections in the past, further treatment with Botox is medically reasonable and appropriate.  The third physician found that there isinsufficient evidence that Botox injections are likely to result in a superior clinical outcome to standard therapy.  The Health Plan denial was overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested acute inpatient mental health treatment for the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  During the dates of service in dispute, the patient was not a danger to herself or to others.  The patient was not impulsive or aggressive.  The patient was medically stable.  Her mood was euthymic, and her speech was logical and goal directed.  She remained anxious and apprehensive, but this did not require inpatient level of care.  The patient was episodically disorganized, but was no longer delusional, psychotic, manic, or impulsive.  The patient was tolerating her medications without side effects.  Her activities of daily living had improved.  All told, acute inpatient mental health treatment from the health plan's date of denial forward were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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.