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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) therapy for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that in this clinical setting the requested services are medically indicated for treatment of this patient. The patient suffers from treatment refractory major depressive disorder and generalized anxiety disorder.  She has failed multiple medications and ECT.  She has a history of two psychiatric hospitalizations, one of which was exacerbated by discontinuation of TMS treatment.  She has had treatment with remarkable results as evidenced quantitatively by her rating scales, reported mood, and objective findings by her treating provider. In sum, continued TMS treatments are 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 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 Nurtec ODT. The American Headache Society (AHS) notes that in individual pharmacological therapies for acute migraine treatment, non-steroidal anti-inflammatory drugs (NSAIDS) and triptans are effective for the treatment of acute migraine attacks. The U.S. Food and Drug Administration (FDA) describes Nurtec ODT as a calcitonin gene-related peptide (CGRP) receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. In a randomized, double-blind, placebo-controlled trial, Croop and colleagues reported that that the percentage of patients achieving headache pain freedom two hours after a single dose was statistically significantly greater in patients who received Nurtec ODT compared to those who received placebo. The authors further reported that there were no serious adverse events or safety concerns. While the AHS guidelines have not yet been updated to include recommendations on CGRP therapies, Pringsheim and colleagues note that when the initial treatment for an acute migraine does not provide meaningful and sustained benefits, a treatment from a different medication class is typically chosen. In this case, the patient has a history of migraines that have not responded to multiple oral abortive therapies and reported side effects with a triptan. Given that Nurtec ODT is an alternative treatment and a different medication class approved by the FDA for the treatment of acute migraines in adults, the requested medication is medically indicated. Therefore, Nurtec ODT is medically necessary 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 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: Upheld

A 30-year-old female enrollee has requested an STD screening including a PAP smear (human papillomavirus (HPV) test) and genital herpes test (HSV-2) for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that according to recent guidelines from the American College of Obstetrics and Gynecology, PAP smears should be initiated at 21 years of age then repeated every 2 years until the age of 30.  HPV screening in young women under 30 is initiated if the PAP smear report returns atypical cells of unknown significance (ACUS) as a method of triage for further diagnostic testing. Routine HPV screening under the age of 30 is not appropriate due to frequent occurrence of the virus in young women who are able to clear the virus with their own immune system without treatment in 8 months to 2 years with no adverse sequelae. Given the above, a repeat PAP smear with HPV testing within such a short interval is not clinically indicated for this patient. Regarding the requested HSV-2 test, genital herpes lesions are quite characteristic and easy to distinguish on exam. In the case of this patient, no lesion was present and she had a serum test that indicated past exposure to HSV-1. This type of HSV can also cause genital lesions and the patients past test may mean she is protected because she has antibodies to fight off recurrent exposure/infection if she has a strong immune system. Repeat screening for HSV-1 and HSV-2 can be confusing without clear cut results. Therefore, there is inadequate support for the requested HSV-2 testing in this clinical scenario.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services. The current medical records do not support the device at issue in this clinical setting. This patient presented with symptoms of congestive heart failure. He was found to have a dilated cardiomyopathy (left ventricular ejection fraction of 25%) and was started on standard goal directed medical therapy. Cardiac catheterization reported normal coronary arteries. In this circumstance, a wearable defibrillator was utilized for primary prevention. Wearable defibrillators have not been shown to be of benefit in this population of patients. The study by Olgin and colleagues failed to show a reduction in sudden cardiac death in the group treated with external defibrillators. A recent meta-analysis concluded that additional controlled trials are needed to justify the use of a wearable defibrillator in the primary prevention setting. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. Therefore, the LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services was not likely to have been more beneficial than any other available standard therapy for treatment of the patients condition.Findings: Two out of three medical experts decided that the LifeVest Wearable Cardioverter Defibrillator provided by Zoll Services was not likely to have been more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: The reviewers determined that the device at issue was not likely to have been 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 reviewer 1 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients short stature. The submitted documentation supports the medical necessity of the requested medication. Based on the specific medical needs of the patient, current literature and published guidelines, this patient would benefit from growth hormone treatment for the diagnosis of idiopathic short stature for the following four reasons. First, this patient has clearly abnormal growth velocity as indicated by the growth chart, which was always growing below the third percentile. Second, the patient had a bone age, which gave an estimated adult height of 147 cm. This is an extremely low adult height. This patient will not be able to function properly as an adult without treatment with a growth hormone and it is expected that the patient might have problems driving, finding adult womens clothing, and shoes, etc. Therefore, it is highly recommended that the patient receive treatment with a growth hormone that will enable a more physiologic adult life. Third, the Food and Drug Administration has approved growth hormone for children with a height that is less than 2.25 standard deviations below the mean, and this recommendation has been endorsed by the Pediatric Endocrine Society and other professional organizations. In this case, the patient has a height that is less than 2.5 standard deviations below the mean, and depriving treatment is likely to have adverse effects on the patients adult life. Fourth, while familial short stature is not an indication for growth hormone treatment, when the familial target height is below the normal adult height that could indicate that one of the parents had an undiagnosed genetic disorder that caused severe short stature. Therefore, a patient can still qualify for growth hormone treatment even in the context of familial short stature, when of course certain criteria are met. Therefore, Nutropin AQ Nuspin is medically necessary 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 total right knee replacement. Based on the recent medical literature with regard to total knee replacement in the presence of obesity, the prevalence of obesity and the utilization rate of total knee arthroplasty are increasing. The data suggests that the rate, as well as proportion, of total knee arthroplasties performed in the presence of obesity and morbid obesity has become more prevalent. Although the presence of obesity increases the risk of cardiovascular complications, with proper precautions, satisfactory in-hospital outcomes are observed after primary total knee arthroplasty. Researchers reported findings of increased mid- to long-term revision rates following primary total knee arthroplasty in the presence of obesity. However, the authors also noted that obese patients experienced functional recovery comparable to non-obese patients. Thus, obesity is not an absolute contraindication to total knee arthroplasty. With regard to the patients age, a total right knee replacement will likely help preserve her quality of life and functional status. The records document the patients right knee pain has failed to improve despite treatment with arthroscopy, partial medial meniscectomy, abrasion chondroplasty, and microfracture, as well as NSAIDs, physical therapy, and corticosteroid injections. Given these findings, the request for a total right knee replacement is medically necessary for treatment of this patients knee pain.Final Result: The reviewer determined that the requested surgery 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 orthopedic 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test, OncotypeDX prostate for evaluation of his prostate cancer. Findings:  Two physician reviewers found that the OncotypeDX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a Genomic Prostate Score (GPS). This test may be utilized to counsel men regarding the best course of therapy (active surveillance vs. treatment) in newly diagnosed low or low-intermediate prostate cancer. Two recent studies have suggested that OncotypeDX can predict adverse pathology and unfavorable outcomes after radical prostatectomy. These studies are recently published and need continued validation from a widespread clinical use. In addition, it is difficult to ascribe clinical utility of OncotypeDX Prostate in patients planning to undergo active surveillance within six months of diagnostic biopsy. Moreover, the validity of using different degrees of tumor pathology as markers to extrapolate the risk of progression of a tumor in vivo is unclear. In addition, current guidelines for prostate cancer suggest that additional evidence regarding the clinical utility of these tests are needed prior to making recommendations as to their routine application. 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. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in urology and is actively practicing. The reviewers 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 fifty-three year-old female diagnosed with intraductal carcinoma of the left breast is requesting authorization for a single-stage mastectomy and breast reconstruction.  The patient has opted for mastectomy to treat the cancer and further selected a contralateral prophylactic mastectomy based on her increased risk of subsequent contralateral cancer. Reviewers Findings:The physician reviewer found that bilateral mastectomy involves a simple mastectomy for treatment and contralateral prophylactic mastectomy for risk reduction. The patient also requests immediate breast reconstruction. There is a potentially better surgical outcome with immediate reconstruction in comparison to delayed reconstruction.  Due to this information the reviewer found that the Health Plan denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested authorization and coverage for genomic exome sequencing analysis (CPT 81415 and 81416). This patients genetic condition, 4q deletion syndrome, is a phenotypically variable syndrome with a wide range of clinical presentations. Specific abnormalities are associated with terminal deletions, including cleft palate and congenital heart disease. Fogel and colleagues noted that clinical exome sequencing is rapidly becoming the new standard for sequencing in genetic diagnostics, as all 21,000 genes in the human genome can be evaluated in an essentially unbiased manner. The authors noted that in instances where phenotypic presentation does not yield a diagnosis, rather than embarking on a series of diagnostic tests, exome sequencing could abbreviate or stop the diagnostic testing cascade by establishing the specific rare diagnosis genetically. Currently, exome sequencing is indicated for undiagnosed neurologic disorders with nonspecific or clinically heterogeneous phenotype, following expert evaluation with detailed history and examination, and genetic testing when deemed appropriate. In this patients case, there is concern about use of growth hormone to address her short stature and stimulation of cancer-causing genes given the predisposition to certain blood cancers. Therefore, the requested genomic exome sequencing analysis (CPT 81415 and 81416) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested genomic exome sequencing analysis (CPT 81415 and 81416) is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested services are 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 reviewer 1 is board certified in genetics and is actively practicing. Physician reviewer 2 is board certified in pediatrics with subspecialty certifications in neurodevelopmental behavioral pediatrics and genetics and is actively practicing. Physician reviewer 3 is board certified in pediatrics with subspecialty certification in pediatric critical care 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.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Aortopathy genetic testing panel and sequencing and/or genetic testing service (CPT 81410). The records provided for review document that this patient has a history of hypermobility as well as a family history of aneurysms. The patient does not have a personal history of aneurysm. In addition, evaluation with echocardiogram was reportedly interpreted as normal. The provider noted that the patient has a history of cranial dissection, but additional information was not included for review. The provider noted concern for Ehlers-Danlos syndrome, and the patient underwent evaluation with genetic testing. Beridze and Frishman noted that vascular Ehlers-Danlos syndrome has a genetic basis. The combination of any two of the major diagnostic criteria should have a high specificity for vascular Ehlers-Danlos syndrome and further testing is recommended to confirm the diagnosis. Per the authors, the major criteria are arterial rupture, intestinal rupture, uterine rupture during pregnancy, and family history of vascular Ehlers-Danlos syndrome. Based on the documentation provided in this case, the patient does not meet the requirements for testing given the lack of major criteria. Harris and Lindsay stated that genetic testing can be beneficial for patients with a known diagnosis of thoracic arterial aneurysm. This patients records do not report a known personal history of thoracic arterial aneurysm. Overall, the patient did not have reported risk factors to support genetic testing for aortopathy or vascular Ehlers-Danlos syndrome. All told, the aortopathy genetic testing panel and sequencing  and genetic testing service (CPT 81410) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the aortopathy genetic testing panel and sequencing and genetic testing service were not likely to be more beneficial for the evaluation 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. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certification in rheumatology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in allergy and immunology and rheumatology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in rheumatology 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.
Appeal type: Experimental/Investigational
Decision: Upheld

A 41-year-old male enrollee has requested ProDisc-L artificial total disc replacement surgery at the L4-5 segment for treatment of his degenerative disc disease. Findings:  Three physician reviewers found that in the treatment of symptomatic lumbar degenerative disc disease, surgery may have a role when there is a demonstrated indication. However, diffuse back pain without an explainable functional deficit or other demonstrated problem, such as instability, is not a sufficient clinical indication for the procedure. Concerns about loss of motion and development of adjacent segment disease following fusion had led to interest in disc arthroplasty as a means of decreasing these problems. As noted by de Kleuver and colleagues, although early results of this procedure were encouraging, problems have been identified including the need for longer follow-up, and the need for well designed, prospective, randomized clinical trials. Currently, there is inadequate evidence to support total disc arthroplasty as likely to result in better long-term health outcomes when compared to standard alternatives. As such, further study is needed to ascertain whether there is preservation of motion, change in adjacent segment disease, and the complications over time. This lack of data was recognized in the original approval of the ProDisc-L by the Food and Drug Administration (FDA) and studies are ongoing. Therefore, the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.