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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for multilevel lumbar fusion from L3-S1. Findings:  The physician reviewer found that in the medical literature, a study recommended surgery for spinal stenosis for patients who do not improve with conservative treatment. Another study found that flatback syndrome can be a significant source of disability, affecting stance and gait, and resulting in significant pain. The authors reported that despite significant complication rates, surgical management to recreate lumbar lordosis using interbody fusions and/or osteotomies can significantly improve quality of life. This patient presented with persistent and worsening severe low back pain radiating into the bilateral lower extremities with weakness on the right side. Functional limitations are noted in activities of daily living. Signs/symptoms are consistent with neurogenic claudication. Clinical exam findings have documented motor deficit and sagittal imbalance consistent with imaging evidence of a rotational scoliosis centered at L3, dynamic spondylolisthesis at L4-5, moderate spinal stenosis at L3-4, and severe facet arthropathy at L3-4, L4-5 and L5-S1. She has severe spondylolisthesis at L4-5, spinal deformity at L3-4, flatback syndrome, and stenosis at L5-S1. Detailed evidence of a recent and comprehensive non-operative treatment protocol trial and failure has been provided for review. There is radiographic evidence of spondylolisthesis with spinal segmental instability on flexion and extension x-rays. The patients condition supports the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. For these reasons, the requested multilevel lumbar fusion from L3-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested multilevel lumbar fusion from L3-S1 is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  The enrollee has requested authorization and coverage for H.P. Acthar Gel for treatment of the enrollees multiple sclerosis (MS).  Findings:  The physician reviewer found that H.P. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of MS relapses. The patient had previously tried IV steroids on two separate occasions for relapses with minimal efficacy. The patient was treated with H.P. Acthar Gel and had a good response. Given the patients poor response to IV steroids, and improved response to H.P. Acthar Gel, the requested medication has been established as medically necessary for treatment of the patients MS. 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 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: Overturned

A 59-year-old female enrollee has requested for Revlimid for treatment of her Non-Hodgkins lymphoma.  Findings:  The physician reviewer found that Revlimid is a newer derivative of thalidomide. It has been approved for use in MDS as well as multiple myeloma and is being very actively studied in Non-Hodgkins lymphoma. Included for review is a reference to the paper by Wiernik and colleagues. In his report, 49 patients with aggressive lymphoma, all heavily pre-treated, were treated with Revlimid. Of these patients, 53% had diffuse large B-cell lymphoma (the same lymphoma this patient has) of which 35% had a response, with 12% being complete responses. The median duration of response was six months. Considering the degree of their pre-treatment, these data were felt to be quite good clinical results. Tempescul and colleagues have also reported a complete remission in a patient with heavily pre-treated mantle cell lymphoma.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 gene test performed on date A and date B. Findings:  The physician reviewer found that Circulating tumor DNA (ctDNA) is shed into the blood stream by tumor cells. The detection of ctDNA in a patients bloodstream depends on many factors including stage, tumor burden, cancer type and rate of cell turnover. The National Comprehensive Cancer Network (NCCN) guidelines for non-small cell lung cancer (NSCLC) recommend measurement of genomic alterations in seven different genes including EGFR, ALK, ERBB2, BRAF, MET, ROS1, and RET because of the availability of 12 different matched therapies. Therefore as the number of genomic targets with matched therapies grows and the tissue biopsy samples are limited, many studies have evaluated the use of ctDNA in NSCLC. On review of the available data, there has been a significant amount of work recently published describing the utility of ctDNA and its role in therapeutic care of patients with NSCLC. Based on the results of this data the U.S. Food Drug Administration (FDA) approved Guardant360 test for EGFR mutations in patients with NSCLC in June 2016 and the most recent version of NCCN guidelines, the testing is supported in the most recent diagnostic and therapeutic algorithm. Guardant360 testing was performed at two different time periods to help direct this patients oncologic care. In this patients clinical situation, the testing provided information about other relevant EGFR mutations which could have supported sensitivity or resistance to treatment. The repeat testing performed in August 2016, although not yet described by therapeutic guidelines as standard practice, was indicated to potentially alert the treating provider of the development of resistance to current therapy. As such, the Guardant360 gene test performed on date A and date B was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 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: Medical Necessity
Decision: Upheld

A 50-year-old male has requested an electric motorized scooter for treatment of his respiratory distress and difficulty with ambulation.  Findings:  The physician reviewer found that the documentation provided for review does not establish the medical necessity of a POV for this patient. Applying the Centers for Medicare and Medicaid Services (CMS) guidelines, the determination of medical necessity for a POV is based on the following criteria: 1) the patient is unable to ambulate independently with use of an assistive device; 2) the patient does not have sufficient upper extremity function to propel a manual wheelchair; 3) the patient has demonstrated the ability and willingness to safely operate a POV; 4) a POV is needed to perform in-home MRADLs; and 5) the patients residence will accommodate such a device. In the case under review, the clinical records do not support the medical necessity of the prescribed POV. A general physical examination notes normal gait and ability to participate in an exercise program and records document unlabored breathing, normal gait, ability to stand without difficulty, and intact cerebellar function. Consistent with this patients level of mobility and ability to perform MRADLs within the home, the requested equipment is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 33-year-old female who was diagnosed with vulvodynia in 2003. She was treated by her gynecologist with topical estrogen, anti-inflammatory creams, antifungal preparations and Elavil, all without apparent success. The patient was referred to an out-of-network provider who specializes in the treatment of vulvodynia. The out-of-network provider instituted treatment with manual therapy and a pudendal block, which has resulted in considerable relief of her pain. The patient has requested authorization and coverage for a referral to a physician who specializes in vulvodynia. The Health Plan has determined the requested referral is not medically necessary for treatment of the patients medical condition.Vulvodynia is an enigmatic disorder, which falls into the broad spectrum of pelvic pain and perhaps into the even broader spectrum of chronic systemic pain disorders. Since the etiology of vulvodynia is unknown and likely to be multifactorial, successful treatment is at best difficult to achieve. In the case of this patient, the correct diagnosis took some time to be made and the patient was then treated with the most appropriate therapies, i.e., topical estrogen, anti-inflammatories, antifungals, and Elavil. All of these medications were ineffective in alleviating the patients pain. At that point, she was referred to an out-of-network provider who specializes in pelvic pain disorders. The provider felt that the patients vulvodynia was caused by myofascial trigger points of the left pelvic floor. He recommended a left pudendal block and manual therapy techniques. Both the patient and the provider felt that the patients symptoms improved with this therapy.As with any chronic pain patient, it is important that the patient be treated by a pain specialist so that she is not receiving uncoordinated care from multiple physicians in multiple specialties. Success of the treatment is dependent upon the targeted (and often unique) therapies for chronic pain and the confidence that the patient has in the specialist. As this patient appears to be obtaining relief with treatment from the out-of-network specialist, the requested referral is medically appropriate and indicated for her continued benefit. Therefore, I have determined that the requested referral is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient received extensive outpatient psychotherapy, medication management and school counseling prior to time of admission. Findings:  The physician reviewer found that he patient expressed a suicidal plan to his friends and their parents, a marked decline in his academic performance, and a decreased interest in social activities. The plan of care was for a higher level of care in a controlled inpatient residential environment to have a sober place to recover safely from his depression with intent to harm self. The American Society of Addiction Medicine (ASAM) supports individualized, person-centered treatment that is responsive to specific needs and patient progress rather than focusing on placement in a program with a fixed length of stay. The ASAM criteria is a set of objective guidelines used by providers to assist with treatment planning. The ASAM advocates for services provided in the least intensive, but safe treatment setting possible for each individual patient. This patient had an adequate outpatient treatment plan that included psychiatric care, psychotherapy and school counseling. He was unable to be safe as an outpatient and had severe depression, passive and active suicidal ideation with a plan. The outpatient providers plan was a higher level of care to assure a sober environment, appropriate medication management, psychotherapy and family therapy, as well as an overall integrative well-being plan. During his stay in residential treatment, it was noted that he had severe depression and weekly thoughts of suicide. The titration of Zoloft to 150mg and addition of Abilify 5mg and melatonin for insomnia, in combination with a multidisciplinary therapy approach, made a critical impact on the patient. He gained tools for emotional expression and abstinence strategies. In reviewing the ASAM worksheet, this patients inability to control substance abuse without 24-hour support and functional deficits support the medical necessity of the RTC services at issue.Final Result: The reviewer determined that the requested services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent 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 patient has requested authorization and coverage for a cardiac catheterization procedure. Findings:  The physician reviewer found that Kannam and colleagues report that in patients with equivocal symptoms and stress testing abnormalities, coronary angiography is often medically reasonable to assess the significance of disease. The authors note that a diagnosis of chronic coronary syndrome can be confirmed by stress testing or, if that is ambivalent, by an invasive evaluation of the coronary circulation. The American College of Cardiology Foundations appropriate use criteria for diagnostic catheterization report that in symptomatic patients with abnormal findings on exercise testing, cardiac catheterization and coronary angiography are medically reasonable and necessary. In this case, the patient has chest symptoms and dyspnea, with significant baseline abnormality of her electrocardiogram (EKG) due to a left bundle branch block, which may be associated with significant coronary disease and be of negative prognostic significance. In this clinical setting, given the patients abnormal stress EKG findings with antero-septal hypokinesis, the requested service is medically indicated. Therefore, a cardiac catheterization procedure is medically necessary for the treatment of this patient.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.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Overturned

A forty-nine year-old female who was treated for right breast cancer, ductal carcinoma in situ is requesting authorization for an MRI.  Reviewers Findings:  The reviewing physician found that indications for MRI of the breast are including evaluation of pre-operative extent of cancer, post-operative residual cancer, extent of lobular cancer, identification of an occult primary cancer with positive axillary lymph nodes, screening of high-risk patients and problem solving.  The reviewing physician found that the health plan denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for 135 hours per month of one-on-one applied behavioral analysis (ABA) therapyfor treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients behavior has improved with a decrease in non-compliance and inflexibility. Tantrums, elopement and aggressive behaviors have been eliminated. Services have been redirected to focus on social and communication skills, aiming to decrease inflexibility, perseveration and passive non-compliance. There is a lack of documentation demonstrating a consistent decline or regression in function during the patients ABA fade out plan. The patients behavioral concerns are predominantly with social skills and the records do not demonstrate that the patient is displaying behavior that is dangerous to himself or to others. For the reasons provided, the request for 135 hours per month of one-on-one ABA therapy has not been established as medically necessary. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tibsovo 250 mg (60 per month). The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of oligodendroglioma note that ideally, all or almost all of the tumor should be surgically removed. The guidelines further note for high risk patients who are over 40 or who have had a partial resection, the best treatment choice may be a clinical trial, radiation followed by chemotherapy with procarbazine/lomustine/vincristine (PCV) or temozolomide, or radiation in conjunction with chemotherapy. Mellinghoff and colleagues note that among 35 patients with progressive nonenhancing gliomas treated with ivosidenib, 85.7% (or 30 patients), achieved stable disease. However, these results are based on a phase 1 trial. Given that the use of ivosidenib is not supported by NCCN guidelines, and as only phase I safety data is available, there is a lack of support in current medical literature for the use of the requested medication over standard treatment. Therefore, Tibsovo 250 mg (60 per month) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Tibsovo 250 mg (60 per month) is 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 requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1 and 2 are board certified internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology and is 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.