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

A 58-year-old female enrollee has requested an extrapleural pneumonectomy for treatment of her non-small cell lung cancer.  Findings:  The physician reviewer found that there is simply no efficacy data on the treatment of patients with T4 NSCLC (malignant pleural effusion) with extrapleural pneumonectomy. Traditionally, these patients do poorly with development of metastatic disease; surgery has no role in the local/regional therapy of patients who present with malignant pleural effusion. Although this procedure has been advocated for mesothelioma, it had not been studied in MSCLC because of the anticipated prognosis of these patients.
Appeal type: Experimental/Investigational
Decision: Overturned

A 69-year-old male has requested coverage for a positron emission tomography (PET) scan for evaluation of his renal cancer.  Findings:  Three physician reviewers found that the patient has undergone right nephrectomy for renal cell cancer. Prior magnetic resonance imaging (MRI) and computed tomography (CT) scans showed liver metastases which have shrunken over time with treatment. The patient has a solitary kidney with impaired function. Laboratory testing reveals that his serum creatinine level is 1.6 and glomerular filtration rate (GFR) is 43. Previous imaging with positron emission tomography/computed tomography (PET/CT) demonstrated that the liver lesions are PET avid, thus his provider has recommended repeat PET/CT to evaluate the remaining liver lesions as well as other sites for potential treatment with radiofrequency ablation (RFA). The provider noted that in addition to screening the two liver lesions, evaluation of the rest of the body is necessary since if the other sites are positive, the patient will not be a good candidate for RFA. Further, the contrast enhanced CT or MRI is not advised due to the impaired renal function and the patients solitary kidney. This patient has known metastatic disease to the liver which has responded to therapy but may still be active. For evaluation, intravenous (IV) contrast enhancement for CT and MRI is not considered safe due to the impaired renal function of the patients solitary remaining kidney. However, in order for CT and MRI to be effective in the detection of metastatic disease, the use of IV contrast is essential. Many metastatic and even primary tumors are only evident with contrast enhancement on conventional CT and MRI scans. While PET/CT has some limited value in the evaluation of metastatic renal cell cancer (RCC) according to the American College of Radiology (ACR) Appropriateness Criteria, PET/CT is likely to be of more clinical value due to the metabolic properties of 18-FDG. In addition, the known PET avid nature of this patients tumor based upon prior PET results increases the probability of its utility for comparative purposes. For these reasons, the requested PET/CT is likely to be more beneficial for evaluation and treatment decision making in this patient than any other available diagnostic procedure or testing.
Appeal type: Medical Necessity
Decision: Upheld

A 35-year-old female enrollee has requested for a referral for treatment of her chronic vertigo and dizziness. Findings:  The physician reviewer found that this patient appears to have poor coping skills, and is unable to move forward despite her symptoms. The most effective treatment is likely to be psychological and behavioral rather than neuro-otologic.
Appeal type: Medical Necessity
Decision: Overturned

A 56-year-old female enrollee has requested for the medication Provigil for treatment of her fatigue.    Findings:  The physician reviewer found that fatigue associated with radiation therapy has been recognized for many years, although the mechanism is not understood. No specific treatment to date has been shown to ameliorate this condition, which can have a profound effect on patient functioning and quality of life. Considerable interest has been devoted to the use of Provigil for radiation related and other forms of treatment related fatigue in cancer patients. There are four ongoing or recently completed studies of Provigil on the National Cancer Institute web site, all of which address fatigue associated with cancer treatment. Since the safety of Provigil has been established for the other approved indications and there are no other available therapies for fatigue related to cancer treatment, the current studies are sufficient to support the off label use of Provigil by this patient.
Appeal type: Medical Necessity
Decision: Upheld

A 47-year-old female enrollee has requested Namenda 60mg per day for treatment of her medical condition. Findings:  Three physician reviewers found that the submitted documentation lacks information concerning the patients diagnosis or previous treatment.  There is no information to confirm a treatment response to Namenda. There is a lack of clinical evidence to support a dose-dependent response of Alzheimers patients to the requested medication.  Additionally, there is inadequate safety data regarding high-dose Namenda. The submitted documentation does not include information regarding standard therapies that have been tried.  All told, Namenda 60mg per day is not likely to be of greater benefit than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old male enrollee has requested for residential treatment center services for treatment of the enrollees major depressive disorder.  Findings:  The physician reviewer found that consistent with American Academy of Child and Adolescent Psychiatry (AACAP) practice guidelines and the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient is an appropriate candidate for RTC services. The records from the provider indicate a diagnosis of major depression and oppositional defiance disorder on admission with poor judgment and poor insight. During the course of treatment at the RTC, there was evidence of progress; however he continues to display behavioral difficulties requiring a structured therapeutic residential setting. The need for 24-hour supervised treatment is reflected in the patients weekly progress notes. The provider indicates he displayed poor impulse control and was disruptive. Further, the progress notes indicate he was easily agitated, and would become emotional during which time he would lose cognitive reasoning. The provider noted that he becomes very agitated and show an increase in temper tantrums. The patients condition is reported to have escalated and such that he had difficulty calming down. Overall, an analysis supports a finding of medical necessity for residential level of care for management of this patients behavioral health issues.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with chronic rhinosinusitis. A sinus computed tomography (CT) scan showed mild mucosal thickening of the left maxillary sinus with opacification of the ostiomeatal complex. The patient reported facial pressure, nasal congestion and postnasal drip. The patient reported he has experienced symptoms for 15 years. The patient was status post sinus surgery two to three years prior. The records indicated that except for a tree allergy, allergy testing was negative. Per the documentation, a two- anda-half month course of allergy shots did not help the patients symptoms. The patient has requested authorization and coverage for Dupixent 300 mg/2 ml. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Dupixent 300 mg/2 ml is medically necessary for the treatment of the patients medical condition. Kim and Naclerio reported, In July 2019, dupilumab was the first monoclonal antibody to gain U.S. Food and Drug Administration (FDA) approval for the treatment of chronic rhinosinusitis with nasal polyposis (CRSwNP). Boyle and colleagues reported, Understanding of CRSwNP pathophysiology has progressively evolved and the identification of various inflammatory biomarkers has led to the development of monoclonal antibodies that target the underlying mechanisms of inflammation. Dupilumab, which targets IL-4 and IL-13 signaling, serves as a novel agent for CRSwNP treatment. In this case, the patients sinus CT scan did not reveal polyps, and the physical examination did not show evidence of nasal polyposis. The medical evidence does not support the requested medication in this clinical setting. Therefore, Dupixent 300 mg/2 ml is not medically necessary for the 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 otolaryngology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for HP Acthar.Findings:  Three physician reviewers found that there is a lack of support for the requested medication in this clinical setting. The available medical records do not adequately document trial and failure of standard psoriatic arthritis treatments, including disease-modifying antirheumatic drugs and biologic agents. Although the records noted that the patient has failed multiple medications, there is a lack of documentation regarding the dosages of medications used or duration of trial of medications. Objective documentation supporting failure of medication trials is lacking. Therefore, HP Acthar is not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in rheumatology 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

A 28-year-old male enrollee requested a functional electrical stimulation (FES) cycle ergometer for medical treatment of the enrollee, who has a spinal cord injury.  Findings:  Three physician reviewers found that the requested device is not likely to be of greater benefit than other treatment options.  This patient is now status post traumatic spinal cord injury.  There is a lack of support for the requested device.  The use of the requested device might carry some increased risk of skin breakdown over insensate areas.  At this level of injury, the patient is expected to be independent at a wheelchair level.  He should be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning.  All told, the requested FES cycle ergometer is not likely to be superior over other treatment options.
Appeal type: Experimental/Investigational
Decision: Overturned

An enrollees parent has requested authorization and coverage for a standing frame device. Researchers described the numerous benefits of standers in patients with cerebral palsy. The noted advantages include improved range of motion and reduced risk of contractures, promotion of vital organ capacity and bone health, and reduction of abnormal muscle tone and spasticity. Researchers also studied the effect of a daily standing program with hip abduction on hip acetabular development in ambulatory children with cerebral palsy. The authors found that a daily standing program with hip abduction in the first five years enhances acetabular development in ambulatory children with spastic diplegia cerebral palsy. Kim and colleagues conducted a meta-analysis to assess the effects of weight-bearing exercise on increasing bone mineral density in children who have cerebral palsy with low bone mineral density. The authors concluded that weight-bearing exercise has a significant effect on improving bone mineral density of the femurs in children with cerebral palsy. Given this patients level of function and risk for secondary complications due to his neurological condition, he is likely to benefit from the requested standing device. Therefore, the requested standing frame device is likely to be more beneficial for treatment of the patients condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested standing frame device is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation medicine 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

The parent of a 17-year-old male enrollee has requested partial hospital program (PHP) services for treatment of the enrollees behavioral health issues.  Findings:  The physician reviewer found that the providers who evaluated this young patient at the time of admission documented that he required long-term treatment in an inpatient setting, with an eye towards gradually stepping him down through levels of treatment. The patient presented with questionable psychotic symptoms intermittently, including auditory hallucinations, and some paranoia, and not only in the context of substance abuse. The psychologist who evaluated and treated this patient over a period of months stated that the patient, presented with one of the most serious cases of major depression I had ever treated during his 17 years of practice. In addition, the patients medications were still being titrated during his inpatient stay, and events were further complicated by the evolution of tics, necessitating holding his medication, treating the tics, and resuming his medications. Moreover, he continued to have intermittent, recurring sleep disturbance, suicidal ideation, and a desire to use substances throughout his inpatient hospitalization. Thus, it was reasonable for the patients providers to have expected that any attempts at treatment would require long-term therapy with gradual advancement in order to best serve the patients interests. Given the gravity of his symptoms, the patient was only transitioned to a lesser level of care when his providers determined that he could be safely and adequately managed in a partial hospital program (PHP), where he remained for services during this period of time. For these reasons, the PHP services provided from the dates in question have been demonstrated as medically necessary and appropriate for treatment of his condition.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested FirstStep Plus genetic testing  for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that Chromosomal microarray (CMA) and Fragile X testing is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorder (ASD) (Schaefer and Mendelsohn). CMA has become the standard of care for diagnosis in patients with ASD. Increasing numbers of patients with ASD have been found to have underlying copy number variations. As such, it is possible that some copy number variations may also be associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ASD due to that underlying cause. Additionally, copy number variations on CMA may inform about other complications and medical risks, some of which can be screened for and treated. All told, the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  Two reviewers are board certified in pediatrics and genetics and are actively practicing. One reviewer is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics. 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: Upheld

A 55-year-old female enrollee has requested reimbursement for 44 sessions of transcranial magnetic stimulation (TMS). The Health Plan has denied this request indicating that the therapy at issue was considered investigational for treatment of the enrollees major depressive disorder. Findings:  Two physician reviewers found that the patient has an approximate 15-year history of clinically significant affective symptomatologies that have been diagnosed both as unilateral depression and bipolar disorder. The patients symptom complex consists of feeling depressed, profound negativity and occasional catatonic like symptoms, along with poor concentration, increased appetite, middle insomnia and episodic suicidal ideations. Her depressive symptoms tend to improve as the day progresses.  The patient has a history of pressured thoughts and speech and grandiosity.  In the medical documentation provided, there is no evidence of a course of an evidence-based psychotherapy or treatment with electroconvulsive therapy (ECT).  The patient has pursued multiple psychotropic medication trials. Psychopharmacotherapy has been reportedly hindered by poor efficacy, lack of sustained clinical effect, and tolerability issues. The patient eventually pursued transcranial magnetic stimulation (TMS) and engaged the treatment modality during an approximate one-month period.  The Health Plan has denied the patients request for reimbursement for this therapy.In 2008, TMS was cleared by the Food and Drug Administration (FDA) as a treatment for major depressive disorder. Subsequent to the FDA clearance, the American Psychiatric Association (APA) investigated this treatment and the available literature.  The outcome of the investigation in 2010 was APA endorsement of TMS for the acute phase treatment of major depressive disorder. The recommendation, however, does not extend to bipolar disorder.  Review of the submitted documentation indicates that this patient was diagnosed with bipolar II disorder by a specialist in bipolarity. Further, her treating psychiatrists diagnoses included rapid cycling as one of the major indicators of the patients diagnosis. There was no evidence provided to refute the diagnosis of bipolar disorder or explanation included to refine the clinical formulation, thus it appears that TMS was used for the depressed phase of bipolar disorder in this case. TMS is not indicated for such use, and accordingly, the use of TMS was not likely to be more beneficial than any available standard therapy in this particular scenario.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for lumbar/sacral transforaminal epidural injection. The American Society of Interventional Pain Physicians (ASIPP) guidelines for epidural steroid injections addressed approaches to repeat injections in a series. ASIPP reported that, In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be two-and-a-half to three months or longer between each injection, provided that greater than 50% relief is obtained for two-and-a-half to three months, not exceeding four per year, per region (Manchikanti, et al.). In this case, the patient has lumbar radiculopathy affecting the left lower leg and heel. MRI has demonstrated multilevel degenerative disc disease and joint disease causing canal stenosis at the lower three lumbar levels and an additional 6 mm disc herniation at L5-S1 displacing the left S1 nerve root, which correlates with the patients symptoms. The patient has tried and failed conservative care and underwent an epidural steroid injection with 40% pain relief and ongoing symptoms. The records do not include documentation of improvement in functional capacity and the patients pain score was 5/10 on follow-up. According to the ASIPP guidelines, repeat injections may be considered when a patient reports at least 50% pain relief for at least three months. This patients response was less than 50% with ongoing symptoms. Given these findings, the requested lumbar/sacral transformational epidural injection is not medically necessary for treatment of this patient. 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 anesthesiology with subspecialty certification in pain management 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.