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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for proton beam therapy.According to Hug, in the vast majority of cases, intensity modulated radiation or three-dimensional conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Furthermore, treatments using deep inspiratory breath hold which move the heart away from the chest wall are also associated with very low cardiac doses in patients receiving radiation for breast cancer. Although the comparison planning shows lower heart doses with the proton plan, the standard plan with photons is not representative of typical cardiac or lung doses with intensity modulation or breath hold techniques. Hug indicated that more evidence is needed to support the use of proton beam therapy for the treatment of breast cancer. Additionally, the National Comprehensive Cancer Network (NCCN) guidelines do not endorse the routine use of proton beam therapy in the treatment of breast cancer. Furthermore, consensus group guidelines do not support the use of proton beam therapy in this setting. In this case, there is insufficient data to suggest that proton beam therapy would be associated with less side effects. Based on these reasons, proton beam therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 radiation oncology 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 55-year-old male enrollee has requested a Jazzy select power wheelchair for treatment of his pulmonary fibrosis and chronic pain.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Based upon the documentation provided, the patient is able to ambulate household distances with supplemental oxygen and therefore does not require power mobility for ambulation within the home. The patient can independently perform his ADLs and therefore does not require power mobility for ADLs. In addition, a power chair is indicated for individuals who require a primary means of ambulation and not a means of community ambulation. Given that the patient is able to ambulate household distances and can independently perform his ADLS, the requested equipment is not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a Shingrex shingles vaccination. The submitted documentation does not support the medical necessity of the requested medication. Varicella-zoster virus (VZV) infection may cause both a primary infection known as chickenpox and a reactivated infection, from latent VZV in nerve cells, known as Herpes zoster or shingles.  The U.S. Food and Drug Administration (FDA) approves the use of Shingrex for the prevention of herpes zoster, or Shingles, in adults aged 50 years or older or in adults aged 18 years or older with immunodeficiency or immunosuppression caused by disease or therapy. Medical literatures note that the vaccine consists of varicella-zoster virus glycoprotein E (gE). In this case, the records reflect that the patient is 46 years of age. The records do not document that the patient is immunocompromised, or that her provider is planning to prescribe medications that will cause the patient to become immunocompromised. While the records note that the provider has prescribed Acyclovir for the patients previous infections of recurrent zoster, there is no documentation of a physical examination of the skin that has confirmed these infections. Therefore, a Shingrex shingles vaccination 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a male enrollee requested 15 hours per week of applied behavior analysis (ABA) therapy, occupational therapy (twice per week) and speech therapy (twice per week) for medical treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that based on the documentation submitted for review, a diagnosis of autism has not been established. The patient has had several evaluations with most reporting a diagnosis of ADHD. The speech therapy report, occupational therapy report and both neurology reports note the patients problems with focus and moving around the room. The patient was reported to have good social reciprocity and good eye contact. The description of this patient is not consistent with a patient with autism. Moreover, the evaluation performed  most recently, diagnosing the patient with autism does not comment on his significant problems with inattention. This evaluation also did not utilize the Diagnostic and Statistical Manual of Mental Disorders (DSM)-V. In sum, this patient presents with findings consistent with ADHD with oppositional and disruptive behaviors; therefore, the requested services are not medically necessary in this clinical setting.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation for treatment of his behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  The record reflects discrepancy with the psychiatric diagnosis.  In a letter dated recently, the provider noted a diagnosis of major depressive disorder.  However, documentation authored by the same provider previously noted a long history consistent with a diagnosis of bipolar disorder, while another provider who has treated the patient for a number of years articulated the diagnosis of bipolar affective disorder in a letter also dated recently.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, the recommendation does not extend to bipolar disorder.  Although there is some preliminary positivism regarding the application of transcranial magnetic stimulation for bipolar disorder, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies.  In this patients case, the records support the diagnosis of bipolar disorder and not unilateral depressive illness.  The medical evidence has not established that transcranial magnetic stimulation is reasonably expected to improve the patients bipolar illness, while the safety and appropriateness of transcranial magnetic stimulation for this indication remain unclear.  Further, it does not appear that the patient has failed other treatments commonly relied upon to treat bipolar disorder.  For example, the patient has not exhausted polypharmacy.  Additionally, it does not appear that the patient has had an informational consultative appointment with an electroconvulsive therapy specialist to learn more about the treatment, which remains a trusted, rapid and effective intervention for both mania and bipolar depression.  Finally, there was a dearth of information regarding the status of supportive relationships and community functioning, or outcomes of non-pharmacological interventions.  Although the patient had tried psychotherapies in the past, there was no reported outcome of cognitive behavioral therapy and it does not appear that he had trialed other evidence-based therapies for bipolar illness, such as family therapy or interpersonal/social rhythm therapy.  All told, transcranial magnetic stimulation is not medically necessary for the 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 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

A 44-year-old female has requested intravenous immune globulin (IVIG) therapy for thre treatment of her asthma, refractory chronic sinus disease and chronic fatigue. Findings:  The physician reviewer found that the practice parameters published jointly by the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI), as well as those published by the World Health Organization (WHO) do not recommend IVIG for treatment of individuals with recurrent infections but normal immune systems. As such, IVIG is not deemed medically appropriate and should not be authorized.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old male enrollee has requested deep brain stimulation for treatment of his thalamic pain syndrome.  Findings:  Two physician reviewers found that the superior efficacy of the requested services has not been established in this clinical setting.  Plow and colleagues conducted a review of deep brain stimulation for chronic pain.  The authors noted that the current medical evidence indicates that these services have not been effective in producing analgesia as intended for patients in this setting.  Nguyen and colleagues examined brain stimulation for the treatment of neuropathic pain.  Per the authors, there is variable efficacy of deep brain stimulation from one patient to another.  The authors reported that there is a need for randomized controlled trials which include a placebo group or period.  Additionally, there is risk of severe adverse effect such as intracranial hemorrhage.  At this time, there is a paucity of evidence regarding the safety and efficacy of deep brain stimulation for chronic pain.
Appeal type: Experimental/Investigational
Decision: Upheld

A 49-year-old female has requested approval for past use of compounded lactose powder 600mg and domperidone 5.5gm for breastfeeding.  Findings:  Two physician reviewers found that the patient adopted a premature infant and wanted to produce breast milk to feed the baby. There is a request from her provider for coverage of the compounded product. The coverage request from the provider states that Reglan had been tried and had failed. She noted that domperidone is not FDA approved, but stated she did not wish to use an FDA approved medication such as metoclopramide (Reglan), because of potential risks, stating that the domperidone did not have any side effects. The patient reported that the medications were successful. There are limited studies on various medications and herbal supplements used to increase milk supply in nursing mothers who have had a decrease in milk production. There are even fewer publications on the topic of using these medications to induce lactation in women who have not given birth. One FDA approved medication, metoclopramide, is often used to increase milk supply. According to Gabay, galactogogues are medications that aid in initiating and maintaining adequate milk production. Most exert their pharmacologic effects through interactions with dopamine receptors, resulting in increased prolactin levels and thereby augmenting milk supply. Metoclopramide remains the galactogogue of choice due to its documented record of efficacy and safety in women and infants. Osadchy and colleagues noted that, There is a controversy within the medical community regarding the role of domperidone as a galactogogue and the drug has been removed from the US market owing to safety concerns. In addition to an FDA warning against the use of domperidone for lactation, the patient was taking oral contraceptives during this time period, which would be inconsistent with trying to breastfeed. All told, the medications at issue were not likely to produce an equivalent or superior health outcome when compared with standard alternative therapies.
Appeal type: Medical Necessity
Decision: Upheld

A 57-year-old male enrollee requested 120 tablets of oxycodone 30 mg, 1 every 6 hours; and Oxycontin 80 mg every 12 hours for medical treatment of the enrollees chronic pain syndrome.  Findings:  The physician reviewer found that the current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy. If there is poor response to conservative therapy then surgery should be considered. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Based on the documentation submitted for review, the requested medications are not medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patients parent has requested authorization and coverage for HP Acthar Gel injections, initiated at 80 units weekly and titrated up to 80 units three times a week as tolerated. Crane and colleagues found that adrenocorticotropic hormone (ACTH)  can be effective at decreasing or eliminating ocular inflammation, and that adverse effects of ACTH are rare and most likely to be reported with relatively high doses of ACTH therapy. Sharon and Chu noted that subcutaneous ACTH gel has shown to be a safe and effective therapy in the management of non-infectious uveitis, specifically in those who do not respond to or are unable to tolerate other immunomodulatory therapies. In this case, the patient has tried and failed alternatives and has an underlying liver condition which makes him unable to tolerate other therapies. Therefore, HP Acthar Gel injections, initiated at 80 units weekly and titrated up to 80 units three times a week as tolerated is medically necessary to prevent disease, disability, and other health conditions or their progression. 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.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 testing provided for evaluation of the enrollees lung cancer. Findings: All three physician reviewers found that the treatment administered to this patient is consistent with the current standard of care as recommended in current guidelines (Ettinger, et al). This patient was initially treated with afatinib for the EGFR mutation found on the initial tissue biopsy. Disease progression prompted the provider to evaluate the patient for the T790 mutation. Options include biopsy of the progressing areas or a liquid plasma biopsy. The progressing areas to biopsy are difficult to access and potentially risky. The technology of a liquid biopsy may be used as a non-invasive biopsy-free alternative to conventional sequencing using tumor biopsy (Kim, et al). This patient tested positive for the T790 mutation and was therefore switched to osimertinib, which is U.S. Food and Drug Administration (FDA) approved for the T790 mutation. All told, the Guardant360 testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three physician reviewers determined that the testing at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewer 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

An 18-year-old male enrollee has requested Xifaxan for treatment of his small intestinal bacterial overgrowth.  Findings:  The physician reviewer found that the benefit of rifaximin (Xifaxan) in treating small intestinal bacterial overgrowth (SIBO) is well-recognized. Scarpellini and colleagues assessed the effects of Xifaxan treatment on 50 children with irritable bowel syndrome (IBS). All patients underwent lactulose hydrogen/methane breath test to assess SIBO before and one month after the treatment with Xifaxan 600 mg daily for one week. Compliance was excellent, and no relevant side-effects were observed during treatment. In addition, Farrell noted that, Xifaxan is a member of the rifamycin class of antibiotics which are currently used to treat serious human diseases including tuberculosis, meningococcal disease, methicillin-resistant Staphylococcus aureus and Clostridium difficile infections and development of resistance to antibiotics with long-term use is a concern. The author concluded that it is advisable that the use of rifaximin as a therapy for IBS should be limited to single, acute, short-term treatment. In this patients case, a post-Xifaxan breath test was not performed to document objective response particularly given the equivocal results seen on his pre-treatment breath test. All told, Xifaxan was not medically necessary for treatment of this patients medical condition when provided on the dates specified.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an minor has requested authorization and coverage for 112 hours per week of home health licensed vocational nurse (LVN) private duty nursing. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case. This patient has a number of problems as a result of and in addition to his myriad neurodevelopmental abnormalities. He requires suctioning as frequently as every 15 minutes, 24 hours per day. It is not safe or reasonable to expect his parent to perform such care to the exclusion of her other responsibilities. Private duty nursing services are thus medically necessary and appropriate for this patient. In sum, the requested 112 hours per week of home health licensed vocational nurse (LVN) private duty nursing 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP). The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is support for a portion of the services at issue in this clinical setting. The patient made gains in her weight since admission to the program increasing her weight from 95.2 pounds to 105 pounds or an IBW of 81% to 89%. The patient reports that she continues to struggle with body checking and feels that she will relapse if she does not have enough support from the IOP. The patient reported that she continues to follow the meal plan at home and at school. The patients weight was 110.2 pounds with an IBW of 93.7%. The patient continued to have high emotional lability, anxiety, and fear of gaining weight. The patient reports that she has strong urges to restrict food intake, but has been completing 100% of her meals/snacks during the program. The patient fears that she will be rejected by her peers once she has restored her body weight. It appears that the patient has been able to remain compliant with her eating plan and functionality at the IOP at three days a week. Due to the patients strong urges to restrict and strong emotional lability, it is highly possible that the patient could relapse and end up in a more restrictive environment. Based on the documentation provided, the patient requires IOP services at three days a week but not at five days per week for treatment of her anorexia nervosa. Therefore, IOP services for three times per week were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise in eating disorders 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.