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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for an implantable heart monitor. Based on the records provided for review, the patient had symptomatic atrial flutter treated with an ablation without recurrent heart racing symptoms. In this circumstance, if evaluation for dysrhythmias is thought to be indicated, then Holter monitoring for frequent symptoms or offline self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations. In addition, offline auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias. There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. An implantable loop recorder was not appropriate in this clinical setting since offline analysis of a patient activated or auto-triggered event recorder would have been sufficient for the identification of dysrhythmias. Identification of recurrent atrial flutter with an implantable loop recorder has not been shown to improve health outcomes compared to standard monitoring techniques, especially in patients with symptomatic arrhythmias. Thus, the implantable heart monitor was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the implantable heart monitor was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the device at issue was 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:  One reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with subspecialty certifications in cardiovascular disease and cardiac electrophysiology and is actively practicing.  One Reviewer is board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned

A 43-year-old female enrollee has requested Remicade 10mg/kg every 6 weeks for the treatment of her ulcerative colitis. Findings:  Three physician reviewers found that it is the standard of care to increase and adjust the dosage of medication when the initial dose stops working. While review of the scientific literature does not reveal any double-blind studies regarding the use of Remicade at a dose of 10 mg/kg every 6 weeks for treatment of ulcerative colitis, there does not appear to be any contraindication to the requested dosage and frequency. In fact, this patient did improve with the higher dose of Remicade administered. Further, the administration of the drug at a frequency of every 6 weeks appears appropriate given the breakthrough symptoms the patient has been experiencing toward the end of the 8-week course. At this stage, the only other option remaining would be surgical intervention, which is invasive and should be avoided if possible.
Appeal type: Medical Necessity
Decision: Upheld

A 45-year-old male enrollee has requested Actiq lollipop for treatment of his brachial neuritis.  Findings:  The physician reviewer found that in the medical literature, Baron and McDonald reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. Consisting with these findings, it is in this patients best interest to wean off Actiq and be treated with adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address his chronic pain. All told, the requested Actiq is not medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for pulse dye laser/V-beam laser treatment for treatment of the enrollees rosacea. Findings:  The physician reviewers found that the treatment of this patients rosacea with the pulse dye/V-beam laser is not supported by definitive evidence in the peer-reviewed medical literature. Traditional treatment for rosacea includes avoiding triggers and topical agents and antibiotics. There is a lack of data suggesting that the use of the pulse dye laser over traditional treatments with topical and oral medication and avoidance of triggering factors is likely to result in superior health outcomes. Final Result: Two of three reviewers determined that the services at issue were not and are 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 number one, two, and three are board certified in dermatology 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: Experimental/Investigational
Decision: Upheld

The parent of a female enrollee requested real-time intra-fraction target tracking (CPT 77387) for medical treatment of her stage III clinical group 3 embryonal rhabdomyosarcoma. Findings:  Two physician reviewers found that real-time intra-fraction target tracking is not likely to be more beneficial to facilitate delivery of proton beam radiation therapy than standard available approaches. At this time, there is a lack of scientific data demonstrating that the use of real-time intra-fraction target tracking results in improved safety and efficacy in the treatment of skull base lesions.  The requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a two-year-old female enrollee has requested for speech therapy, occupational therapy, and physical therapy for treatment of the enrollees developmental delays.  Findings:  The physician reviewer found that speech disorders are identified when a patients voice, fluency, or articulation call attention to the speaker because his or her speech is sufficiently different from the norm. Speech and language development should be consistent with a patients overall development and can be tracked using typical milestone markers. With regard to occupational therapy, Case-Smith and Arbesman concluded that the research literature offers strong positive evidence for providers to use comprehensive, individualized analysis of the patients performance to develop the intervention strategies. The research evidence also supports the use of family-centered, interdisciplinary approaches. Many of the studies used play-based or activity-based interventions such as those implemented by occupational therapists. In the medical literature, Shevell and colleagues concluded that an etiologic diagnosis is often possible in the young child with global developmental delay, particularly in the absence of autistic features. Additionally the American Academy of Neurology (AAN) practice parameters recommends evaluation of children with non-progressive global delay since a specific etiology can be determined in the majority of children with global developmental delay.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Gamunex-C intravenous immunoglobulin (IVIG) home infusions. There is a lack of clinical trial data reported to establish effective treatments for the management of patients with statin-triggered autoimmune myopathy. The consensus during the 224th European Neuromuscular Centre (ENMC) International Workshop defined anti-HMGCR myopathy in patients with (a) elevated serum creatinine kinase (CK) levels, (b) proximal muscle weakness, and (c) anti-HMGCR autoantibodies (Allenbach, et al.). The ENMC group reached consensus regarding treatment recommendations for patients with anti-HMGCR myopathy and noted that IVIG should always be added within six months when other treatment strategies are ineffective. In this case, the patient has clinical and laboratory findings consistent with anti-HMGCR myopathy and a history of diabetes. Per the ENMC consensus group, IVIG should be considered as monotherapy in anti-HMGCR myopathy patients with contraindications to or intolerance of high dose steroids as in this patients clinical setting due to comorbid diabetes. In addition, the published clinical studies have demonstrated that IVIG is an effective and a well-tolerated alternative to steroids in diabetic patients with statin-induced autoimmune myopathy. Mammen and Tiniakou reported that three patients with diabetes who declined treatment with glucocorticoids were treated with IVIG. The authors concluded that, our experience suggests that monotherapy with IVIG may be considered as a first-line treatment for statin-triggered autoimmune myopathy. Gungor and Wieshmann described a case report of a diabetic patient who had severe statin-induced autoimmune myopathy. The authors reported that the patient made a full recovery with regular IVIG infusions, his symptoms relapsed when the IVIG infusions were discontinued for 28 weeks, then his symptoms remitted again following recommencement of IVIG infusions. The data suggest that IVIG infusions are an effective and well tolerated alternative to steroids and immunosuppressants. Given this support, the requested Gamunex-C IVIG home infusions are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 patients parent has requested reimbursement for the residential treatment center (RTC) services provided for treatment of the enrollees suicidal ideation, self-harm and depression.Findings: The physician reviewer found that progress notes indicate the patient denied symptoms of depression and reported anxiety that was mild to moderate. During the remainder of his stay, the patient had oppositional behaviors, but was primarily cooperative in treatment. The progress notes did not indicate the patient had any active suicidal ideation or attempted suicide. In cases such as this, an evidence based instrument such as the child and adolescent level of care utilization system (CALOCUS) is indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. Applying the CALOCUS, this patient had some risk of harm (score 2) due to his history of impulsive actions and aggression. However, the medical records indicate that the patient was not actively suicidal and only expressed intermittent suicidal ideation with no intent or plan to harm himself. The patient experienced moderate functional challenges (score 3) due to some school disruption. Since the patient did not have active serious medical problems or any significant substance use issues, his co-morbidity was mild (score 2). The patients recovery environment was mildly stressful (score 2) with a positive recovery environment and a stable housing situation, and the patients parents were involved with treatment and supportive (score 2). The patient has demonstrated some resiliency in treatment (score 3) due to no significant and noted treatment successes. The patient was overall constructive in treatment (score 2), and was noted to participate in therapy and use coping skills learned in therapy. Moreover, his parents constructively work with the patients providers (score 2). This gives the patients presentation a composite score of 18 which correlates with intensive outpatient (IOP) services. Thus, the patient could have been safely and effectively treated in a less restrictive setting. In summary, the RTC services provided were not medically necessary for treatment of this patients behavioral health issues.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 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: Overturned

A 43-year-old female enrollee has requested Xifaxan 200mg, twice a day for treatment of her gastroparesis.  Findings:  The physician reviewer found that Xifaxan (rifaximin) is used to treat traveler's diarrhea caused by certain bacteria. Xifaxan is in a class of medications called antibiotics. It works by preventing the bacteria from growing inside the intestine. It is common for patients with bacterial overgrowth to develop bloating, cramping and dyspepsia. In an already symptomatic patient with gastroparesis (such as this patient), this combination can be particularly troublesome. However, there is no clinical rationale for chronic antibiotic use. A brief (10-day) dosage of antibiotics will generally clear bacterial overgrowth for a three to four month period. Therefore, this patient should be approved for a 10-day course of Xifaxan every three months as needed. A dose of 200-400mg three times a day would be medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

A 20-year-old male enrollee has requested for Avastin infusion treatments for treatment of his metastatic Ewings Sarcoma.  Findings:  The physician reviewer found that Avastin in the Phase I setting, and found the dose that they wished to move forward in Phase II trials. The Phase I trial had 5/18 patients who were evaluable and 3 of them had Ewings (out of a total of 5 patients with Ewings enrolled).  The drug was able to provide them longer periods than predicted to progression, but did not show shrinkage of the tumor. The Phase II trial uses this agent in combination with chemotherapy and is ongoing.  There is not sufficient information at this time to recommend the use of Avastin for this indication outside of a clinical trial.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Xeljanz 5 mg for treatment of the enrollees alopecia.  Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting.  This patient has experienced full regrowth of her hair with Xeljanz therapy, having already failed treatment with oral steroids, topical steroids, intralesional steroids and anthralin.  Xeljanz is a janus kinase inhibitor approved by the U.S. Food and Drug Administration for the treatment of rheumatoid arthritis. There is increasing evidence of its utility in the treatment of severe cases of alopecia areata, a disease for which few useful therapies exist. This patient has already tried and failed the standard therapies with steroids and anthralin. There is very limited treatment options for her type of alopecia and she has already shown excellent response to Xeljanz. Therefore, Xeljanz 5 mg is medically necessary for 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 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: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that Neuralgia is a type of neuropathic pain. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia specifically refers to pain and/or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. The patient has been diagnosed with occipital neuralgia on examination. Per the records, she had a severe form of occipital neuralgia which was unresponsive to noninvasive, minimally invasive, and invasive procedures.  Although the data is limited, there is evidence to suggest effectiveness of nerve decompression for the treatment of her condition. However, the patients history is well-documented, and the chronicity of her complaints combined with her treatment history speak against the emergent nature of her disease process. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.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

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. Based on CALOCUS criteria, this patient does not meet the criteria for RTC level of care. The patient has been at low risk of harm (score 1) as evidenced by notes reporting progress in skills and no reports of self-harm or suicidal ideation. The patient has demonstrated mild functional impairment (score 2) as she has caught up in school and although she still reports some bouts of anxiety and worry, these symptoms have been manageable. The patient has significant comorbidities (score 3) considering her history of generalized anxiety disorder and depression as well as substance abuse. However, the patient demonstrated positive skills development in a contained treatment environment. The patients recovery environment has been moderately stressful (score 3) since the patient has been able to navigate the RTC environment in a positive manner, but continued to have significant anxiety requiring support. The patients recovery environment has been supportive (score 2) as the notes indicate the patients family has made efforts to support the patient, although the mother-child relationship is noted to be strained and difficult. The patient has shown significant resiliency to treatment (score 2) with lack of improvement in lower levels of care. The patient has exhibited the improved ability to manage stressors as evidenced by the ability to maintain gains despite the stress of a conflict with a peer. The patient has been constructive in treatment (score 2) as the patient has been an active participant in the RTC milieu. This gives the patient a composite score of 15, which is consistent with low intensity community based services. Given these findings, the RTC level of care services were not and are not medically necessary for treatment of this patient.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 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical repair for treatment of his medical condition.  Findings: The physician reviewer found that diastasis recti is reserved for patients who have not had a previous midline celiotomy. It is common in smaller women after pregnancy where the midline between the rectus is stretched out. The bleeding from the stitch granulomas can be handled electively as an outpatient under local anesthesia. If it does progress to recurrent partial obstruction or significant enlargement, a case could be made for laparoscopic lysis of adhesions and large underlay ventral hernia repair. However, the records do not document an indication for the requested surgical repair of the ventral midline surgical scar diastasis. Thus, the requested surgery is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Qualifications/Credentials: The physician reviewer is board certified in 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.