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

A 58-year-old female enrollee has requested acute hospitalization for the treatment of her major depressive disorder, recurrent, severe, with psychotic features, rule out possibility of schizoaffective disorder, anxiety, not otherwise specified, and alcohol dependence.  Findings:  The physician reviewer found that the patient has a well-documented history of psychotic depression, alcohol dependence and a recent suicide attempt. The medical notes on the said date indicated that the patient was very anxious regarding unexpected news of impending discharge.  The patient was discharged. On the same day, she was readmitted. An analysis indicates the patient met criteria for acute inpatient care during the initial time period at issue. Additionally, acute hospitalization during the second time period at issue was medically necessary for the treatment of this patient.  At this time, resumption of acute hospitalization is not medically indicated for this patient.  At the time of discharge, the patient was not acutely suicidal and was no longer delusional. She was a candidate for transitioning to an intense lower level of care, such residential treatment.  All told, acute hospitalization during the time periods at issue were medically indicated. Resumption of acute hospitalization is not medically indicated for this patients treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old male enrollee has requested for transcranial magnetic stimulation (TMS) for treatment of his depression.  Findings:  Two physician reviewers found that he has suffered from depression and presented with depressed mood, anhedonia, sleep disturbance, fatigue, anxiety and impaired concentration. He has been treated with clomipramine, Risperdal, Wellbutrin, Effexor, Pristiq, Zyprexa, Abilify, Prozac, Nortriptyline, Lexapro, and Remeron. The records indicate the patient has been given transcranial magnetic stimulation (TMS) using the NeuroStar system.The Food and Drug Administration (FDA) has not approved TMS as a therapeutic device for any neuropsychiatric disorder, including depression. Moreover, there is a paucity of evidence in the form of randomized clinical trials establishing the safety and efficacy of TMS for the treatment of psychiatric disorders other than depression, such as schizophrenia and anxiety.
Appeal type: Urgent Care
Decision: Overturned

A 24-year-old female enrollee has requested emergency services provided for treatment of her menstrual cramps.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the principal determinate of the need to seek evaluation in an emergency department was the degree of pain that the patient was experiencing. The fact that she had a pain level of 8 out of 10 constitutes grounds for a prudent layperson to have thought this to be an emergency medical condition and to have sought immediate medical attention in an emergency department. Thus, the patients symptoms on the date in question met prudent layperson criteria for emergency care.
Appeal type: Experimental/Investigational
Decision: Overturned

A 37-year-old male enrollee has requested AlloMap molecular expression testing for evaluation of his status post heart transplant.  Findings:  Three physician reviewers found that results of a randomized clinical trial have shown that a strategy using AlloMap testing is an appropriate alternative to a strategy using routine endomyocardial biopsies in stable patients at low risk for rejection who were six months to five years after cardiac transplantation.  This patient fits these eligibility criteria since he was at low risk of rejection based on the prior echocardiogram and prior endomyocardial biopsy results. Additionally, he was greater than six months but less than five years status post cardiac transplant. AlloMap molecular expression testing performed on the date in question was likely to have been more beneficial than available standard therapy since it had been demonstrated to be an effective alternative in this circumstance and involved less risk compared to invasive endomyocardial biopsy.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara (ustekinumab), 90 mg subcutaneously (SQ) every four weeks. The submitted documentation supports the medical necessity of the requested medication regime. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab has been demonstrated to be safe and effective for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-TNF therapy. In a study of patients with anti-TNF resistant Crohns disease, researchers observed an initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, the patient had symptoms consistent with active  disease on Stelara 90 mg every eight weeks. While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory results dated reported a low Stelara level of 0.3 ug/mL, and the patient was placed on a dosing regimen of every four weeks. Discontinuation of dosing every four weeks or a change to another medication may result in loss of disease control, with complications such as fistula, stricture, bowel obstruction, flare, hospitalization, need for surgery, or other complications. Therefore, Stelara (ustekinumab), 90 mg SQ every four weeks, is medically necessary for the 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 internal medicine with sub-specialty certification in gastroenterology 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 enrollee is requesting authorization and coverage for Cutaquig. The enrollee has a history of autoimmune thyroiditis and immunoglobulin G subclass deficiency. The physician recommended continued intravenous immunoglobulin G therapy. The physician reported the enrollee is at an elevated risk due to the COVID-19 crisis, and that the enrollees severely compromised immune system cannot protect her from this virus. This enrollee is diagnosed with immunoglobulin G subclass deficiency, but the only subclass that is low is immunoglobulin G-4, which is low in a small percentage of enrollees with no immune dysfunction.  In addition, the immunoglobulin G-4 level in this enrollee is two, whereas a level of less than or equal to one is typically considered low.  Literature recommends the primary treatment for immunoglobulin G subclass deficiency is treating any concomitant allergy, using prophylactic antibiotics, and then judicious use of polyclonal human immunoglobulin G in selected enrollees. This enrollee has not received the former treatments yet; therefore, not a candidate to start immunoglobulin replacement therapy at this time. Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for weekly 50-minute sessions with a mental health provider and nutritional counseling services. Researchers noted that, psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and can help in preventing depressive relapse and recurrence. This recommendation is consistent with the American Psychiatric Association (APA) guidelines, which state that, to prevent a relapse of depression in the continuation phase, depression-focused psychotherapy is recommended. Moreover, medical literature found that psychotherapy is a first-line intervention for patients with bulimia nervosa. Psychotherapy has been shown to help reduce patients symptoms, but needs to be continued for maintenance of bulimia nervosa and major depressive disorder. The standard of maintenance psychotherapy is weekly, which is appropriate to treat this patients bulimia nervosa, major depressive disorder, and generalized anxiety disorder. Given this support, the requested weekly 50-minute sessions with a mental health provider and nutritional counseling services are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 55-year-old male has requested Provigil for treatment of bipolar disorder.  Findings:  The physician reviewer found that the progress notes submitted for review do not clearly outline the progression of the patients symptoms or his response to treatment. It does not appear that mental status examinations were conducted at regular intervals and there is no clinical support for the addition of Provigil to the patients medication regimen.
Appeal type: Medical Necessity
Decision: Overturned

A 57-year-old female enrollee has requested for a DEXA bone density study for evaluation of her bone density. Findings:  The physician reviewer found that per the recommendations of the National Osteoporosis Foundation, a baseline DEXA scan should be obtained in women age 50-64 with a family history of osteoporosis.  In addition, this patient sustained a foot fracture, although the submitted documentation does not indicate whether the fracture was non-traumatic in origin.  Risk factors for osteoporosis include genetic disorders, family history, hormone deficiency, hormone excess, immobilization and microgravity, tobacco abuse, alcoholism, malignancy, medications, and certain systemic diseases. The DEXA scan is used to determine the bone density of the lumbar spine and hips.  The study is indicated for patients who are at risk for osteoporosis or osteomalacia and for patients with pathologic fractures or radiographic evidence of diminished bone density.  Osteoporosis is usually asymptomatic until fractures occur.  The current medical evidence supports the requested diagnostic procedure in this clinical setting.  All told, the requested DEXA bone density study is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested self-injectable testosterone injection (cypionate) for treatment of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Low testosterone can lead to complications including reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue.  For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL.  The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly.  This patient has clinical and biochemical evidence of hypogonadism and is likely to benefit from testosterone replacement therapy.  Therefore, self-injectable testosterone injection (cypionate) is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (molecular profiling) performed.  Findings:  The physician reviewer found that the patient is diagnosed with lung cancer. She presented with a right mediastinal mass that proved to be lung adenocarcinoma. She had superior vena cava syndrome and extension of tumor to critical vasculature as well as formation of a fistula. A tumor sample was submitted for Guardant360 mutational testing. The patient requested reimbursement for the gene test (molecular profiling) performed. The Health Plan denied reimbursement for the services at issue stating that the gene testing was investigational for the evaluation of this patient. Recent medical evidence demonstrates the superior efficacy of the services at issue in this clinical setting. The Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 genes. Recently, a clinical study directly compared the use of targeted agents with conventional chemotherapy approaches. A study involved 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors.  Invariably, this patient will be offered something off-label or a phase I/II clinical trial but the results from molecular profiling offers a rational selection of the next regimen. The therapy for advanced non-small cell lung adenocarcinoma (NSCLC) has been revolutionized by the finding of epidermal growth factor receptor gene (EGFR) mutations in certain adenocarcinomas.  The mutations are more common in those who have never smoked. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Furthermore, the American Society of Clinical Oncology issued guidelines include EGFR testing. All told, gene test (molecular profiling) performed was likely to have been superior over the standard options available for the evaluation of this patients medical condition. The reviewers determined that the services at issue were likely to have been 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 1, 2 & 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: Experimental/Investigational
Decision: Overturned

A 62-year-old female enrollee has requested for intravitreal Avastin (bevacizumab) injections for treatment of her proliferative diabetic retinopathy (PDR). Findings:  Two physician reviewers found that the uses of bevacizumab continue to evolve, and its off-label applications have benefited many ocular conditions.At this juncture, other therapies are warranted and further injections of bevacizumab are unlikely to improve the macular edema.Given the possible association of elevated blood sugars with triamcinolone injections and the patients hyperglycemic response, it was reasonable to try bevacizumab.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 49-year-old male with bilateral Tarlov cysts on S2 nerve roots. The patient reports a history of back and leg pain. The patient has undergone an orthopedic consultation and multiple neurosurgical consultations. He wishes to undergo surgical removal of the Tarlov cysts. The Health Plan has determined the requested procedure is not medically necessary for treatment of the patients medical condition.Review of the submitted materials indicates the patient has received multiple evaluations and diagnostic procedures. The submitted records include no evidence that the patients Tarlov cysts are causing either his back or leg pain. The requested procedure is not likely to have any effect on the patients symptomatology. There is no medical indication for operative intervention in this patient. Therefore, I have determined the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old female enrollee has requested for an EML4-ALK Rt PCR Pathology Test for evaluation of her lung cancer. Findings:  Two physician reviewers found that the EML4-ALK fusion oncogene defines a new molecular subset of non-small cell lung cancer with distinct clinical and pathologic features. The patients who are most likely to harbor EML4-ALK are relatively young, and never have been or are light smokers with adenocarcinoma. These same features are associated with epidermal growth factor receptor mutation; thus it is essential to screen patients by genetic testing and not rely solely on the presence of clinical predictors. The results of genetic screening can then be used to choose the appropriate molecularly targeted therapy. Pre-clinical studies showed that the presence of EML4-ALK confers sensitivity to ALK inhibitors both in vitro and in vivo, and suggest that patients with this gene rearrangement may derive clinical benefit from specific ALK inhibition. Preliminary results from a phase I/II study demonstrate that the ALK inhibitor crizotinib is active in patients whose tumors harbor the EML4-ALK fusion gene.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast reduction surgery for treatment of his Klinefelters syndrome.  Findings: The physician reviewer found that this patient presents with significant bilateral gynecomastia in the setting of a low testosterone state, consistent with Klinefelters syndrome. The examination documentation is consistent with severe abnormal male breast enlargement and more consistent with female anatomy. Thus, the requested surgery is to correct a congenital breast deformity known as severe gynecomastia. The procedure is expected to significantly improve the patients appearance and would make a more than minimal improvement. Consistent with this finding, the requested bilateral breast reduction surgery is reconstructive in nature and medically necessary.  Final Result: The reviewer determined that the requested surgery is reconstructive in nature and medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Qualifications/Credentials: The physician 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: Upheld

Findings:  The physician reviewer found that An enrollee has requested reimbursement for DecisionDx-Melanoma genetic testing. This patients records document a history of malignant melanoma, superficial spreading type, with a maximum tumor thickness of at least 0.5 mm, with peripheral margin involved by melanoma in situ. A sample of the patients tumor was submitted for analysis with DecisionDx-Melanoma testing. The data available from the peer-reviewed medical literature does not support the routine use of the DecisionDx-Melanoma test after sentinel lymph node biopsy (Gerami, et al.). In addition, the National Comprehensive Cancer Network (NCCN) does not recommend the DecisionDx-Melanoma assay for the evaluation and treatment planning of patients with melanoma. The two prospective studies discussed within the NCCN guidelines indicate that the patients analyzed were a high risk cohort. There has also been a lack of consistency between various genes being used as biomarkers. Given these findings, the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the DecisionDx-Melanoma genetic testing was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.