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

A male enrollee requested valsartan for medical treatment of his hypertension. Findings:  The physician reviewer found that the records note a history of hypertension.  However, there is no documented coexisting condition that would provide an indication for a specific class of antihypertensive medication.  In this clinical setting, the current guidelines recommend that initial antihypertensive treatment should include a thiazide-type diuretic, a calcium channel blocker, an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker.  Each of these four drug classes has yielded comparable outcome effects with respect to overall mortality, cardiovascular disease and renal disease.  Since there is no documented compelling indication for an angiotensin receptor blocker, such as valsartan, and no documented intolerance to other antihypertensive medications, the requested medication valsartan is not medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old male enrollee has requested CyberKnife radiosurgery for the treatment of his unresectable hilar cholangiocarcinoma. Findings:  Three physician reviewers found that locally advanced, metastatic gallbladder cancer has a poor prognosis. Radiation is used primarily for palliation of symptoms from local progression, such as biliary obstruction, bowel obstruction and splanchnic nerve pain.  Decades of literature indicates that radiotherapy with unresectable gallbladder cancer is medically indicated.  Chemotherapy also is used for palliation, and the standard treatment in patients with reasonably good performance status is to offer both chemotherapy and radiation. With newer technology, newer tools are available to deliver the radiation. CyberKnife is a delivery system which allows for SBRT delivery, using real-time monitoring of fiducials, coupled with robotically controlled tracking of these fiducials.  In theory, CyberKnife treatment may afford an advantage in terms of improved local control. However, the literature on the use of SBRT for gallbladder cancer is lacking because it is such a rare malignancy.  There is a growing body of literature on the use of SBRT for locally advanced pancreatic cancer.  All patients have poor survival, although some studies report excessive toxicity, while others do not. For this patients case, there is no evidence to support that a CyberKnife boost improves local control or symptom palliation.  SBRT may in fact increase toxicity. In a patient with metastatic disease, SBRT/CyberKnife is also less advantageous given the expected poor survival.
Appeal type: Experimental/Investigational
Decision: Upheld

A 66-year-old female has requested Rituxan for treatment of her autoimmune hearing loss.  Findings:  Three physician reviewers found that the patient has had a progressive fluctuating hearing loss in her left ear since the 1990s. On work-up, she was diagnosed as having autoimmune inner ear disease. The diagnosis was based on her response both to transtympanic and systemic steroids. She did not reportedly respond to other available immunosuppressive medications. Her left ear continues to decline, and treatment with Rituxan has been proposed. There are data supporting the use of Rituxan for some autoimmune conditions, and the study from Cohen and colleagues suggests this medication may be effective in autoimmune inner ear disease. This patient may be a candidate for a structured clinical trial of Rituxan. However, its use has not been established by appropriately designed, randomized, and double-blinded clinical trials to be expected to provide this patient with an improved health outcome when compared with standard therapies.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The parent of a male enrollee has requested reimbursement for acute inpatient psychiatric services. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Applying the child and adolescent level of care utilization system criteria to determine the appropriate level of care, the patient demonstrated some risk of harm (score 2) due to his history of aggression. The patients functional status was moderately compromised (score 3) given his issues with role performance due to psychiatric symptoms. The patient did not have any medical, addictive, or psychiatric co-morbidity (score 1). His recovery environment was mildly stressful (score 2) and he was noted to have a stable living environment. The patients recovery environment was supportive (score 2), he demonstrated resilience to prior treatment (score 3), and was constructive and engaged in treatment (score 2) although he was also noted to engage in attention seeking behaviors and was non-compliant with staff. The patients parents were constructive (score 2) and worked actively with providers. This gives the patients presentation a composite score of 17, which correlates with intensive outpatient services. The records provided for review document that this patient was initially admitted to the acute inpatient setting due to a reported failure of prolonged residential treatment. The progress notes indicate that during the initial portion of the stay the patient did not have many behavioral outbursts and his mood was often described as euthymic. As his stay progressed, the patients behavior worsened and he became defiant with treatment and exhibited numerous attention seeking behaviors. Progress notes indicated that he had intermittent passive suicidal ideation. The progress notes do not document any significant improvement in the patients behavior while he was at the inpatient level of care. Accordingly, the inpatient psychiatric services 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing called ThyGenX.  Findings:  Three physician reviewers found that fine needle aspiration (FNA) biopsy yielded cytology which was consistent with papillary thyroid carcinoma (Bethesda Category VI). A specimen was subsequently sent for ThyGenX molecular analysis. While an FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among these tests is ThyGenX, which analyzes a panel of DNA mutations and RNA translocation fusion markers to assess the risk of malignancy with good negative and positive predictive value, obviating the need for unnecessary surgeries. ThyGenX has emerged as a promising method for clarifying the gray area of indeterminate thyroid FNAs.  However, in the case of this patient, her initial cytology was not indeterminate. The nodule was consistent with papillary thyroid carcinoma. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld

The parent of a 15-year-old male enrollee has requested 25 hours per week of applied behavioral analysis (ABA) therapy for treatment of the enrollees autism. Findings:  The physician reviewer found that although autism is a life-long condition, the literature pertaining to the treatment of adults and teenagers with autism is quite limited. The bulk of ABA literature is concentrated in its application to young children. The medical communitys customary and usual prescription for autistic children is ABA therapy and the medical literature strongly supports the use of ABA therapy for the treatment of children with autism. However, when reviewing ABA as applied to adults and teenagers, there is limited literature substantiating the favorable effect of intensive therapy on these populations. This is particularly true in individuals who carry a co-morbid diagnosis of autism spectrum disorder and intellectual disability, such as this patient (Marriage, et al.). In this patients case, 17 hours per week has been authorized of ABA therapy. There is a lack of evidence demonstrating that increasing the numbers of hours of ABA therapy beyond this level will result in improved functional capacity in this case. As such, the medical necessity of 25 hours per week of ABA therapy has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Pen for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient was intolerant of methotrexate and is reported to have failed treatment with Otezla.  However, the medical records fail to demonstrate how long the trial of Otezla was prior to stopping.  The records do not document a trial of injectable methotrexate.  The severity of the skin disease is not known, and the severity of the arthritis appears to be mild per the records.  Methotrexate is the preferred agent in psoriatic arthritis.  The records fail to demonstrate that the patient has failed the preferred non-biologic agents for her disease, and the Health Plans requirement that the patient try at least 12 weeks of dose optimized, oral DMARD therapy is medically appropriate.  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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in rheumatology 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

The parent of a 14-year-old male enrollee has requested Femara therapy for the treatment of the enrollees short stature. Findings:  Two physician reviewers found that the patients provider has submitted very substantial recent studies confirming this treatment as successful. These studies suggest that this is no longer experimental treatment. The requested therapy is medically appropriate.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested 16 additional hours of home health shift care for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a complex medical condition that requires close supervision and care.  This care should be provided either through home health care or a skilled family member.  The Health Plan has approved coverage for 40 hours of home health shift care per week, which is medically appropriate.  The records do not document the need for greater than 40 hours of home health shift care.  All told, the requested additional 16 hours of home health shift care is not medically indicated 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 pediatrics 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 22-year-old female enrollee has requested Cymbalta 60 mg for treatment of her complex regional pain syndrome and anxiety.  Findings:  The physician reviewer found that Cymbalta is medically necessary for treatment of this patients medical condition. The records document that the patient has tried and failed to benefit from standard therapies and her condition is seriously debilitating. Cymbalta is supported in the peer-reviewed medical literature as a safe and effective treatment for combined disorders of chronic joint pain, neuropathy, and depression. Raskin and colleagues performed a multicenter double-blind randomized controlled trial to assess the efficacy and safety of Cymbalta on the reduction of pain severity in patients with diabetic peripheral neuropathy. The study demonstrated that Cymbalta was superior to placebo. They concluded that Cymbalta 60 mg once per day and twice per day was effective and safe in the management of diabetic peripheral neuropathy. Skljarevski and colleagues performed a randomized double-blind placebo controlled study to assess the efficacy and safety of Cymbalta in patients with chronic low back pain. The authors found that Cymbalta treated patients reported greater reduction in pain than the placebo-controlled group. The authors concluded that the data demonstrates efficacy and safety of Cymbalta in the treatment of chronic pain. Given these findings, the requested Cymbalta 60 mg is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for Xifaxan 550 mg (three times a day for 14 days). In this case, the patient has a diagnosis of irritable bowel syndrome (IBS) with diarrhea. Pimental and colleagues note that among patients who had IBS without constipation, treatment with rifaximin (brand name Xifaxan) for two weeks provided significant relief of IBS symptoms, bloating, abdominal pain, and loose or watery stools. Lembo and colleagues note that in a phase 3 study of patients with relapsing symptoms of IBS with diarrhea, repeat rifaximin treatment was efficacious and well tolerated. The American College of Gastroenterology recommends the use of rifaximin for reduction in global IBS symptoms, as well as bloating in non-constipated IBS patients. In this clinical setting, current medical literature supports the use of the requested medication. Therefore, Xifaxan 550 mg (three times a day for 14 days) is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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

A 51-year-old female enrollee has requested computed tomography (CT) angiogram for evaluation of her abnormal electrocardiogram.  Findings:  Two physician reviewers found this patient had some coronary risk, no cardiac symptoms, a documented normal cardiovascular physical examination and a reported abnormal electrocardiogram.  In this circumstance, if the electrocardiogram were abnormal and suspicious for possible coronary ischemia or myocardial infarction, then stress testing would be the initial standard accepted practice.  Coronary CT angiography was not medically necessary in this circumstance since it only assesses anatomy and not the functional significance of any stenosis identified.  In addition, if an assessment of coronary anatomy were thought to be medically necessary, then conventional coronary angiography would be preferred due to its improved accuracy relative to coronary CT angiography and the ability to intervene with percutaneous coronary intervention during the same procedure, if clinically indicated.  Current guidelines endorsed by several national organizations also do not consider coronary CT angiography appropriate in asymptomatic patients with no known coronary artery disease.  Therefore, CT angiogram was not likely to be of greater benefit than other options for evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase in tramadol dose. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees medical condition. Nationally recognized evidence based medical guidelines recommend tramadol as an option for pain treatment. Tramadol is indicated for treatment of moderate to severe pain. There is limited information to recommend this drug for neuropathic pain. The immediate release formulation is recommended at a dose of 50 to 100 mg by mouth every four to six hours (not to exceed 400 mg per day). Opioids appear to be efficacious, but should be limited for short-term pain relief in patients with acute low back pain. Long-term efficacy is unclear (greater than 16 weeks), and there is also limited evidence for the use of opioids for chronic low back pain. Failure of activity level to respond to a time-limited course of opioids has led to the suggestion of reassessment and consideration of alternative therapy. Overall, the safety of long-term use has not been adequately studied, and some non-randomized prospective studies suggest opioid treatment may actually impede functional recovery.  Researchers concluded that the evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms. Medical literature shows chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in conjunction with other modalities of treatments in low doses with appropriate adherence monitoring and understanding of adverse events. This patient presents with chronic pain relative to lumbar degenerative disc disease and arthritis, status post back surgery. There is no indication provided to support the medical necessity of an additional increase in tramadol dose. The records do not support an escalation in dose or that the patient is achieving pain reduction and functional improvement with the use of this medication, and there are no side effects or aberrant behaviors. Therefore, the request for an increase in tramadol dose is not medically necessary for 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that The patient has requested authorization and coverage for acupuncture services. While conventional medicine has not yet developed effective treatments or clinical practice guidelines for the treatment of long COVID-19 due to the new and evolving nature of the condition and limited number of cases, current medical literature does support the use of acupuncture for the treatment of similar symptoms. Morehead and Salmon note that the efficacy of acupuncture has been proven for nausea and vomiting related to pregnancy, in patients receiving chemotherapy, and in postoperative, pediatric, and female patients. Streitberger reports that results from 26 trials showed that acupuncture-point stimulation was effective for both postoperative nausea and vomiting, concluding that there is good clinical evidence from more than 40 randomized controlled trials that acupuncture has some effect in preventing or attenuating nausea and vomiting. In this case, the patient underwent several therapies with limited relief of her symptoms including oral medication, patches, and vestibular therapy. Following five sessions of acupuncture, the patient reported significant improvement in sense of smell, dizziness, and nausea, allowing for a reduction in medication usage. In this clinical setting, given the patients benefits obtained with prior acupuncture care and the literature support for the use of acupuncture to treat nausea, the requested services are medically indicated. Therefore, acupuncture services 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.