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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested laboratory testing for the level of infliximab and antibodies in the blood for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Many providers are using this testing as a standard of therapy after starting infliximab to judge whether a patient will benefit from the drug.  The testing allows providers to determine if the serum levels of drug are in the range to be beneficial and effective or if there are antibodies that could potentially lead to a reaction or failure to respond.  This can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication.  This can not only prevent the patient from having a flare up but save them from potential side effects of a drug they may not benefit from.  All told, the services at issue were likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two 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:  All three reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, the patient does not meet the criteria for RTC level of care services. Although this patient is demonstrating difficulty functioning, the RTC setting is not considered the most effective treatment modality for patients with oppositional defiant disorder. He requires pharmacological, psychological and environmental treatment, but the documentation does not support RTC level of care services. The records suggest the patient is at low potential for risk of harm The physician reviewer found that  due to self-harm by cutting with recurrent suicidal ideation. The patient has demonstrated moderate impairment of functioning (score 3). He has significant comorbidities including bipolar disorder, ADHD, and GAD (score 3). The patients recovery environment is moderately stressful (score 3) given his contentious relationship with his father. The patients recovery environment includes his mother, who has been supportive (score 2). The patient has demonstrated poor response to treatment and recovery management (score 4). The patient has been obstructive to treatment (score 3). The providers notes state that the patient continues to display poor judgment and combativeness. His mother has been constructive with the patients treatment (score 2). This gives the patient a composite score of 21, which is consistent with medically monitored community based services. Therefore, the RTC level of care services were not and are not medically necessary for treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 55-year-old female enrollee has requested for a PET scan for evaluation of her condition.   Findings:  Two physician reviewers found that a review of the peer-reviewed literature, including the National Cancer Institute and American Society of Clinical Oncology and National Comprehensive Cancer Network, showed no medical evidence to support the use of PET imaging in patients with a diagnosis of cholangiocarcinoma. The standard imaging studies that are routinely utilized in the staging and restaging of cholangiocarcinoma include CT and MRI. There is a lack of evidence to support the use of PET scan over standard imaging studies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for weekly allergy/immunotherapy injection. Findings: The physician reviewer found that Allergy shots are indicated for persistent symptoms on a seasonal and/or perennial basis and those with an inadequate or partial response to environmental control and medications.  Both national allergy organizations recommend skin testing and allergy shots as an effective treatment for allergic rhinitis, asthma and atopic dermatitis.  Studies have shown that allergy shots over medications for the treatment of allergic rhinitis and asthma have been effective.  However, in this case, the patients medical records fail to demonstrate signs and symptoms consistent with allergic rhinitis. Additionally, the records fail to demonstrate failure of primary therapy, which includes avoidance as well as medications.  The records appear to be requesting injections for buildup and maintenance therapy. It is unclear from the records why the patient would continue to require weekly shots once on maintenance and would not be able to space out injections as recommended in the national guidelines. According to the guidelines, weekly allergen/immunotherapy would not be recommended in this patients case. As such, the medical necessity for weekly allergy/immunotherapy injection has not been demonstrated for treatment of this patients medical condition. Final Result: The reviewer determined that requested medication quantity is 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 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 a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

A 36-year-old male enrollee has requested Zolinza 100mg for treatment of his glioblastoma multiforme. Findings:  The physician reviewer found that Zolinza (vorinostat) is a relatively new drug that falls into the class of histone deactylase inhibitors. These drugs can induce cell growth arrest, differentiation or cell death. This medication has been approved for use in cutaneous T-cell lymphomas. There are ongoing protocols in glioblastoma treatment incorporating vorinostat with chemotherapy. However, at this time, there is only one report of its use in glioblastoma as sole therapy. In this report by Galanis, et al., 66 patients were treated on a phase II trial. Overall, 9 of the 52 patients were progression-free at six months. The median survival was 5.7 months. The authors concluded that the drug is well-tolerated and has modest activity. No other clinical outcome data on the use of Zolinza in this particular setting is available. As such, there is insufficient evidence demonstrating that the requested medication is likely to benefit this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 40 hours of per week of applied behavioral analysis (ABA). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The request for 40 hours of per week of ABA is not medically necessary for treatment of the enrollees autism spectrum disorder. Medical literature shows both intensity and duration of ABA therapy positively influences a favorable outcome in autistic patients, but the authors indicate that after the age of 12 the outcome of ABA therapy is not influenced by either duration or intensity. In addition, researchers found support community inclusion and development of social and living skills for the treatment of adults with autism. Given the medical literature cited above, the request for 40 hours per week of ABA therapy has not been established as medically necessary for treatment of the patients medical condition.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 and neurology with special qualification in child 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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Lyrica 50 mg, three times a day. Findings:  The physician reviewer found that treatment with Lyrica was beneficial in the past. However, the records do not specify how Lyrica helped the patient. There is no description in the progress notes to support an indication for Lyrica. The patient is on several anxiety medications. The progress notes do not indicate that the patients anxiety is the focus of treatment. The documentation suggests that his functional impairment and problematic symptoms are due to his psychosis. The progress notes indicate the patients target treatment goals are psychotic symptoms, consisting of delusions, and sleep disturbances affecting his interpersonal relationships. Lyrica has U.S. Food and Drug Administration (FDA) approval for diabetic neuropathic pain, post herpetic neuralgia, fibromyalgia, partial onset seizures, and spinal cord pain. Lyrica is not indicated to treat delusions or psychosis (Martin, et al; Griebeler, et al). Furthermore, Lyrica does not have FDA approved indications for any of the patients current documented diagnoses. Therefore, Lyrica 50 mg, three times a day, is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 46-year-old female enrollee has requested hormone therapy with testosterone pellet implants for the treatment of her perimenopausal symptoms. Findings:  Two physician reviewers found that the use of subcutaneous hormone replacement therapy (HRT) has been reported for many years. Subcutaneous HRT is particularly useful when patients require testosterone supplementation. Subcutaneous testosterone supplementation has been shown to be effective in improving bone density and treating reduced libido and other psychosexual problems. There is no other option currently available (such as transdermal patches) that is as reliable as this method. Transdermal creams and gels cannot be delivered in consistent, accurate doses. Estradiol replacement can be offered simultaneously with subcutaneous testosterone supplementation, providing good benefit and convenience.
Appeal type: Medical Necessity
Decision: Overturned

A 33-year-old female enrollee has requested for chiropractic care for treatment of her migraines and cervical-occipital neuralgia. Findings:  The physician reviewer found that the patient is experiencing considerable pain and functional limitations due to a pinched nerve at the C2-3 level causing neck and shoulder pain and likely contributing to her headaches. The Mercy Guidelines support chiropractic treatment for neck pain. There is sufficient evidence in the literature to support the use of chiropractic treatment in managing spine pain, motion restriction, stiffness, and functional limitations, and  the patient is an appropriate candidate for such services.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for Genotropin. The submitted documentation does not support the medical necessity of the requested medication. The patient does not meet standard criteria for growth hormone deficiency. The patients insulin-like growth factor-1 level prior to initiation of growth hormone therapy was normal, and provocative growth hormone testing revealed normal results. The patient does not meet criteria for treatment with growth hormone therapy for idiopathic short stature.  a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests, but who meet most of the following criteria. The criteria include height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum insulin-like growth factor-1 and/or insulin-like growth factor binding protein and/or other clinical features suggestive of growth hormone deficiency. This patient does not meet the above criteria. This patients clinical presentation is most consistent with a diagnosis constitutional delay. Therefore, Genotropin is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested for residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that there is a lack of evidence demonstrating that the patient would not be able to maintain sobriety at a less restrictive setting.Although psycho-social issues usually have an impact on substance use, there was minimal documentation of the strategies used to help the patient retain sobriety after she left treatment.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center for resumption of residential treatment services.  Findings: The physician reviewer found that the Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The submitted documentation supports the medical necessity of the services at issue.  This patient has a long pattern of unstable behavior that severely poses a threat to herself as well as other people.  Her enmeshment with her mother and anger towards her father pose a risk for her to continue her treatment unless she is removed from that environment to a residential treatment facility.  She has demonstrated that she was a risk to herself after her premature discharge from residential treatment center level of care.  Residential treatment level of care by definition is long-term treatment, and the program is constructed so that the first few days allow the patient to develop some comfort in her surroundings before any significant therapy begins.  The medical evidence supports the services at issue in this clinical setting.  All told, residential treatment center services and resumption of residential treatment services were and are medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with 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: A patient has requested authorization and coverage for Otezla 30 mg, one tablet by mouth twice daily. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients plaque psoriasis. The submitted documentation does not support the medical necessity of the requested medication regimen. This patient has had a trial of Otezla, with some improvement.  The patient has not tried and failed the preferred formulary agents, including methotrexate, cyclosporine, acitretin, Cosentyx, Enbrel or Humira. There is no medical documentation as to why the preferred agents cannot be used. The diagnosis of hyperlipidemia does not preclude the use of methotrexate, as there is no documentation of transaminitis due to statin therapy. In this clinical setting, there are alternative formulary agents that may be used for the treatment of this patient. Therefore, Otezla 30 mg, one tablet by mouth twice daily 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 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: Overturned

A 30-year-old female enrollee has requested monthly intravenous immune globulin (IVIG) therapy for the treatment of her multiple sclerosis (MS). Findings:  Three physician reviewers found that IVIG is not a first-line therapy for MS, but has been shown to benefit the relapsing-remitting MS population. This patient has failed first-line therapies, and is not a candidate for other commonly used agents. She had a favorable response to IVIG in the past. For this particular patient, the use of IVIG therapy offers the best opportunity for stabilizing her disease and is medically indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

The parent of a 15-year-old female enrollee has requested  for tilt-table testing for evaluation of the enrollees orthostatic symptoms.   Findings:  Two physician reviewers found that the literature suggests that orthostatic hypotension associated with postural tachycardia syndrome (POTS) cannot be diagnosed by using sitting and standing blood pressures, and instead requires performance of a tilt table test. This makes sense when one considers the multi-factorial nature of dysautonomia that may be involved in patients with POTS. This may include significant dysregulation from a variety of factors, including but not limited to baroreceptor dysfunction, vestibular inputs, carotid body function, as well as the potential conditioning that may occur in experiencing near-syncopal symptoms. Many potential stressors are simply obviated with having the patient quickly stand after sitting, but not all can be eliminated without the use of an operator-assisted tilt table.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of her metastatic breast cancer. Findings:  Two physician reviewers found that radiofrequency ablation of liver metastases is often used in situations where the lesions cannot be surgically excised. Most of the data relevant to radiofrequency ablation treatment of liver metastases is in the treatment of colon cancer. Although it is a treatment used reasonably often, there has been conflicting data as to its efficacy, and in whom it should be used. Researchers reported on a series of studies done in breast cancer patients.  The authors concluded that the technique could be considered in patients who either had no extrahepatic disease or stable extrahepatic disease. The criteria for the applicability of the technique were the same as reported in another study.  In this patients case, the records documented metastases to the lung and bones, as well as a liver metastasis which was 9 mm in size.  Per the records, there was some degree of progression of these extrahepatic metastases. There is a lack of support for the services at issue in this setting.  Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are 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.