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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX test (CPT 81519) for evaluation of the enrollees breast cancer ductal carcinoma in situ (DCIS).  Findings:  The physician reviewers found that recently, several groups have identified panels of gene expression markers/signatures that appear to predict the baseline risk of breast cancer recurrence after surgery, radiation therapy and endocrine therapy for hormone receptor positive tumors in women with node negative disease. This test is generally used for T1, T2 estrogen receptor positive, node negative patients to estimate risk of distant metastasis. In this case, the patient has DCIS. This test stratifies patients into high and low risk groups. At this time, the evidence is insufficient to determine the effects of this technology on health outcome of patients in this clinical setting. As such, the services at issue were not likely to have been more effective than the available standard therapy for the evaluation of this patients medical condition. Final Result: All three reviewers determined that the services were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in radiation oncology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a sleep study for evaluation of the enrollees sleep apnea. Findings:  The physician reviewer found that in terms of current medical literature and the standards of practice, a sleep study was not medically necessary in evaluation of this patients medical condition. Standards of practice require adequate pre-test documentation, which is lacking in this case., Further, per the post-test clinical documentation, the patient had classic signs and symptoms to suggest the presence of obstructive sleep apnea (OSA). As a result, there was no compelling reason supported by the literature to support the need for attended testing. Moreover, the patients records did not indicate that the patient had any contraindications to home sleep testing.  All told, the services at issue were not medically necessary in evaluation of this patients sleep apnea. Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested Botox for treatment of her intractable migraines. Findings:  Three physician reviewers found that Botox injections for episodic, chronic, tension type headaches may provide substantial improvements in symptoms for some patients who are refractory to pharmacotherapy. Despite this contention, the current scientific data does not demonstrate statistically significant outcomes between Botox treatment groups and placebo. The references confirm that Botox treatment of migraine headaches remains in the experimental stage and is not FDA approved for this indication. In addition, it is not preventative of migraine headache and has not been established through well designed clinical trials to be more effective than standard treatments that are proven, first-line therapies. As the records do not support a diagnosis of spasmodic torticollis, the patients migraine headaches may well be managed with conventional, proven alternative treatment modalities. For these reasons, the requested Botox treatment remains investigational and experimental for management of this patients condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment center services provided for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that Based on the documentation submitted for review, RTC services provided and forward were not and are not medically necessary for treatment of the patients medical condition. The patients treatment team states that the patient does not have insight into her mood and behavior problems and does not have coping skills for day-to-day functioning. However, the provider notes that the patient is generally cooperative and she feels that the structure is helping her. She has no suicidal ideation and is not harming herself, other than picking on her face. Prior to admission, she was aggressive toward her family for taking away her phone. However, the provider noted that she had learned to tolerate being without her phone during the admission. Her functional scale ratings showed that she had improved in performing her hygiene and dressing most days and engaging in physical activities. Based on the documentation provided, there is a lack of rationale supporting continued RTC level of care. In this clinical setting the patient could safely transition to a lower level of care such as a partial hospitalization program (PHP). The structure of a PHP daily routine will allow for the patient to continue to work on transferring learned skills to the home environment, and she would be able to continue an intensive therapy schedule while receiving weekly psychiatric treatment. For the reasons provided, the services at issue were not and are not medically necessary for treatment of the patients medical condition. 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 reviewer is board certified in psychiatry with sub-specialty 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electrical stimulation and ultrasound therapy. Based on the available documentation, the requested transcutaneous electrical nerve stimulation (TENS) and ultrasound therapy are not medically necessary for treatment of the patients low back pain. A recent literature and meta-analysis found that TENS may provide short-term functional benefit but not pain relief. Medical literature reported short-term functional benefit with therapeutic ultrasound. The records indicate that this patient has complaints of low back pain treated with chiropractic care. However, this patients provider has not provided a rationale for the use of TENS or ultrasound in a proposed treatment plan. Overall, the requested electrical stimulation and ultrasound therapy are not medically necessary for treatment of the patients low back pain based on review of the literature and medical records. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:A 60-year-old male enrollee has requested authorization and coverage for Uloric 40 mg tablet for treatment of the enrollees stage III chronic kidney disease and foot pain. Findings:  The physician reviewer found that As noted by Becker and colleagues, an indication for pharmacologic urate-lowering therapy in patients with a diagnosis of gout is gout with renal insufficiency. Thus, it was reasonable to attempt first-line therapy with a xanthine oxidase inhibitor (XOI), such as allopurinol, for this patient. However, since the medication was not tolerated, an alternate agent is required. Uloric has also been effective in safely reducing the serum urate in patients with moderate to severe renal impairment, as shown in a randomized 12-month trial involving 96 such patients who were treated with 30 mg twice daily, 40 mg once daily (increased after one month to 80 mg once daily if serum urate was  6 mg/dL after 14 days of therapy), or placebo (Saag, et al). Although uricosuric agents are another option for urate lowering, probenecid is likely to be ineffective in patients with moderately impaired kidney function. Thus, this agent would not be ideal for this patient. Further, Becker and colleagues noted that Colcrys is generally given as short-term therapy (ie, for periods not exceeding six months duration) to prevent acute attacks during the initiation of antihyperuricemic therapy because it is potentially toxic. In summary, the available evidence and current recommendations support the medical necessity of the requested Uloric 40 mg tablet for treatment of this patients medical condition. 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 nephrology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi 400 mg tablets for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  This patient should be considered treatment-naive as he has failed peg-interferon rather than peg-interferon with ribavirin in the past.  At this time, the guidelines do not recommend Sovaldi with ribavirin for this patient with hepatitis C, genotype 2 infection.  This is based on the significantly higher effectiveness of two other regimens, Epclusa, and Sovaldi with Daklinza.  For these reasons, the requested medication regimen is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is 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 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: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested BRCA testing for evaluation of her family history of cancer.  Findings:  Two physician reviewers found that the medical records note that she does not have a personal history of cancer.  The patients father was diagnosed with prostate cancer at 80 years of age, and her mother was diagnosed with breast cancer at 78 years of age.  Additionally, her grandfather was diagnosed with colon cancer in his 80s, a cousin was diagnosed with rectal cancer at age 62, and an aunt was diagnosed with breast cancer in her 60s.  BRCA mutations are associated with a high incidence of both breast and ovarian cancer.  Information regarding whether a patient is BRCA positive can have several implications with regards to patient management.  As to breast cancer, patients may consider more intense screening or bilateral mastectomies.  With regards to ovarian cancer, patients may elect to undergo bilateral salpingo-oophorectomy.  According to National Comprehensive Cancer Network Guidelines, women without cancer should be tested if there is a first-degree or second-degree relative diagnosed with breast cancer who also fulfills other criteria, such as young age, two breast primaries, or triple negative cancer.  In this patients case, she is Ashkenazi and her mother had breast cancer.  Per current recommendations, BRCA testing is not indicated at this time.  It is medically appropriate to undergo testing with an Ashkenazi panel prior to performing BRCA testing.  The medical records do not indicate that an Ashkenazi panel has been provided.  All told, the requested BRCA testing is not likely to be superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a regimen of three (3) Rituxan 1,000 mg infusions. Researchers note that rituximab is considered a first line treatment for moderate and severe pemphigus vulgaris. The authors note that the usual dosing regimen is two infusions of 1,000 mg, spaced two weeks apart, and a third dose as early as six months after the initial infusions. In this case, the patient has a diagnosis of pemphigus vulgaris. Given current medical literature, the requested medication regimen is medically indicated in this clinical setting. Therefore, a regimen of three (3) Rituxan 1,000 mg infusions is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A 45-year-old female enrollee has requested for continued Rocephin IV for treatment of her Lymes disease. Findings:  Three physician reviewers found that There is a lack of evidence of any infectious process to explain the patients symptoms.  With regard to Lyme disease, there is no mention of a tick bite or an erythema migrans eruption. The clinical symptoms described are all non-specific and do not suggest a diagnosis of Borrelia infection. The definitive tests for Lyme disease (IgM and IgG Western Blots) were negative in 2005.  The only positive test for Lyme disease (a urine multiplex) is not a widely recognized or standardized test and is not recognized as being of value by Centers for Disease Control. There is also no evidence of infection with Babesia, except for a positive Babesia FISH assay.  Again, this is not a standard test, and it is not widely used or recognized.  Even if there were evidence of Lyme disease, in almost all forms of disease, the initial recommended therapy is an oral tetracycline. Ceftriaxone is recommended for documented central nervous system disease, myocarditis or persistent or recurrent arthritis.
Appeal type: Medical Necessity
Decision: Upheld

The patient has requested reimbursement for intensive outpatient program (IOP) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 2.1 criteria for IOP services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the IOP services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in addiction 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing. Findings:  Three physician reviewers found that FibroTest has been demonstrated to reliably determine the presence of advanced fibrosis and cirrhosis in a variety of liver diseases, including hepatitis C. Patients with cirrhosis due to hepatitis C or other causes require management of cirrhosis to avert complications.  Liver biopsy, unlike FibroTest, is invasive, with risks including bleeding and bile duct injury. It is subject to interoperator variability during interpretation, and it is also subject to sampling error. The current medical evidence supports the laboratory testing performed in this patients case. Thus, laboratory testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for Vertiflex device placement at two levels. The enrollee has lumbar spinal stenosis at L3/4 and L4/5, causing bilateral neural foraminal stenosis and continued, long-term use of opiate analgesics. The enrollee has failed non-opioid therapies, including acetaminophen, non-steroidal anti-inflammatory drugs, muscle relaxants, neuropathic agents, epidural steroid injections, facet blocks, and radiofrequency ablation. He reports functional improvement and decreased pain with opioid pharmacotherapy. The enrollees advocate indicates the enrollee has utilized conservative treatment for six months without significant pain relief. Continued conservative treatment is not expected to yield substantive clinical improvement. Review of the record does not support the medical indication as to why the interspinous process spacer devices should be used rather than standard treatment. There is a lack of evidence to support that interspinous spacer devices are superior in efficacy and safety compared to the standard treatment of decompression. Additionally, there is concern the interspinous process spacer devices lead to higher rates of re-operation. Scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome to support this service as likely to be more beneficial than any other standard treatment.Final Result: Two of the three reviewers determined that the requested services are not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in orthopedic surgery 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.
Appeal type: Experimental/Investigational
Decision: Overturned

A 58-year-old female enrollee has requested the addition of Avastin (bevacizumab) to her chemotherapy regimen for treatment of her recurrent ovarian cancer.  Findings:  Two physician reviewers found that Bevacizumab (Avastin) has been studied in several phase II studies and has shown clinical benefit in relapsed ovarian carcinoma. Avastin is an active agent for platinum-refractory epithelial ovarian cancer, both alone and in combination with cytotoxic chemotherapy. It is currently one of the recommended treatment options for recurrent ovarian cancer. Thus, the addition of Avastin to this patients proposed chemotherapy regimen would be considered standard of care.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 12-year-old female enrollee has requested FM system (hearing device) for treatment of the enrollee, who has been diagnosed with dysfunction of the corpus callosum. Findings:  The physician reviewer found that the submitted records demonstrate the medical necessity of the requested device in this patients case.  The records indicate hearing that there is history of diagnosis of central auditory processing disorder (APD).  Per the current literature, FM technology refers to a type of wireless system that helps people better understand speech in noisy situations.  FM systems commonly work together with a patients hearing aids, although systems are also available for those with otherwise normal hearing.  The current literature supports the use of an FM auditory amplification system, even in patients with measured normal hearing, in the context of APD.  All told, the requested FM system (hearing device) is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A female enrollee requested Herceptin for treatment of her transverse colon adenocarcinoma.  Findings:  Two physician reviewers found that the requested medication is not likely to be superior over other treatment options.  Foundation One assay explores the mutations or gene overexpression of an individuals cancer cells.  However, at this time, there is a lack of evidence demonstrating that the assay adds to decision-making above and beyond the tests which are available conventionally.  There is a lack of data supporting the use of Herceptin in colorectal cancer.  Therefore, the requested medication Herceptin is not likely to be of greater benefit than other treatment options.