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 carisoprodol (Soma) 100 tablets per 30 days for treatment of the enrollees chronic cervical and lower back pain.Findings:  The physician reviewer found that Based on the documentation submitted for review, the medical necessity for the requested medication has not been established. Current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Additionally, the medical literature indicates that Soma is a muscle relaxant with more addictive and abusive properties than opioids. Soma is a centrally acting muscle relaxant, associated with a high risk of dependence and tolerance. Long term administration is not recommended. Baron and colleagues reported that high dose opiates and centrally acting muscle relaxants might contribute to sensitization via 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 opioids and other medications such as Soma for a chronic medical condition reported a significant decrease in pain at the end of the study, further supporting the theory of hyperalgesia.  Ballantyne and colleagues also reported that prolonged use of centrally acting medications might induce tolerance and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of medication therapy. In this patients case, prescribing Soma would be contradictory to providing safe and effective treatment. As such, the carisoprodol (Soma) 100 tablets per 30 days is not medically necessary for the treatment of this patients medical condition. 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 anesthesiology with sub-certification in pain 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: An enrollee has requested authorization and coverage for Humira 40 mg/0.8 ml pen. The submitted documentation supports the medical necessity of the requested medication. This patient has tried and failed therapy with topical steroids. The Health Plan noted that the patient has not yet tried and failed the preferred formulary first-line systemic agents, including methotrexate, cyclosporine or acitretin. However, because the medical records show significant transaminitis, the use of methotrexate or acitretin would not be recommended in this case. Per the records, the Health Plans preferred oral systemic agents would be contraindicated due to comorbidities. Therefore, Humira 40 mg/0.8 ml pen 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 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: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Amitiza for treatment of the enrollees irritable bowel syndrome with constipation.  Findings: The physician reviewer found that the request for Amitiza is not medically necessary for treatment of the patients medical condition. According to the U.S. Food and Drug Administration (FDA) The safety and efficacy of Amitiza was established in two major studies involving 1,154 patients diagnosed with IBS-C. The majority of the patients studied were women (approximately 8 percent were men). The efficacy of Amitiza in men was not conclusively demonstrated for IBS-C. Amitiza is not approved for use in children and men. In this case, the records do not demonstrate that the patients IBS-C is advanced, nor do the records show that he has maximized treatment with approved step therapy. In sum, Amitiza has not been established as medically necessary for treatment of the patients IBS-C.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 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: Medical Necessity
Decision: Upheld

A 58-year-old female enrollee has requested lorazepam 1mg for treatment of her anxiety disorder. Findings:  The physician reviewer found that the notes indicate a pattern of drug-seeking behavior.  Her history is significant for an overdose of medication with near fatal results, requiring more than 10 days of treatment.  Lorazepam has addictive qualities. Michel and Lang reviewed some of the forensic aspects of this medication and noted that the adverse effects of benzodiazepines have been well-known for several decades. They include drowsiness, behavioral disinhibition, hostility, rage and addiction.  This patient has been offered safer medication alternatives, which she has declined. All told, lorazepam 1mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a 13-year-old female has requested applied behavioral analysis (ABA) therapy that incorporates Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity for treatment of autism.  Findings:  The physician reviewer found that applied behavioral analysis (ABA) has been shown to be beneficial in the treatment of behaviors associated with autism spectrum disorder (Granpeesheh, et al). Treatments based on operant principles of learning are more effective for reducing maladaptive behaviors than alternative treatments. Multiple studies of Lovaas-based approaches and early intensive behavioral intervention variants resulted in some improvement in cognitive performance, language skills, and adaptive behavior skills (Sallows and Graupner). Individual treatment is a defining feature and integral component of ABA. The Individual Program Plan for this patient is constructed to identify all behavioral needs including communication, functional living, self-help skills, social interaction, and recreation. These domains are noted as program components for intensive ABA therapy. All told, the ABA therapy incorporating Discrete Trial Training, task analysis, Pivotal Response Training, incidental teaching methods, and group activity, is medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patient has requested skilled nursing facility (SNF) services. Findings:  The physician reviewer found that the records provided for review document that the patients medical condition has stabilized and he is ready for discharge from the hospital. He does not require skilled nursing or skilled therapy services on a daily basis. Although further rehabilitation services are appropriate to improve function, the daily skilled services can be provided at a lower level of care than a SNF. All told, admission to a SNF for inpatient skilled rehabilitation services is not medically necessary for treatment of this 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 internal medicine with expertise in skilled nursing facilities 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

An enrollee has requested authorization and coverage for a consultation with a pain management specialist. In this case, the patient has persistent low back pain which has been managed with Norco three times a day. The patients last two urine drug screens have been inconsistent, due to the absence of prescribed Norco and the presence of marijuana and alcohol. Records indicate that there was an additional concern of possible tampering with urine samples. Records reflect that the provider made a plan to taper Norco and to offer Suboxone, which was declined. The provider also made a referral to a pain management specialist, which is appropriate given that the patient would be exploring non-opioid and non-pharmocologic treatments, consistent with CDC guidelines. Accordingly, the requested consultation with a pain management specialist is medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary to treat the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology, with subspecialty certification in pain 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: Experimental/Investigational
Decision: Upheld

A 38-year-old female enrollee has requested an ambulatory cardiac event monitor for evaluation of her heart palpitations and rapid heart rate.  Findings:  Two physician reviewers found that based on the records provided, the patient has a history of shakiness and rapid heart rate in the setting of a normal cardiovascular physical exam and a normal ECG. In this circumstance, self-activated non-real time and non-continuous monitoring devices (event recorders) should be effective at recording potential dysrhythmias during symptoms that are not frequent enough to be identified on continuous 24-48 hour Holter monitoring. In cases of infrequent asymptomatic dysrhythmias that require identification, non-real time (off-line) monitoring devices with auto-triggering capability should be sufficient. This patients records offer no documentation to indicate that she is unable to effectively manage these standard monitoring devices and or that these have been previously obtained to evaluate the patients symptoms. The current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and patient activated event recorders appropriate initial tests for evaluation of supraventricular dysrhythmias. Consistent with these guidelines, the continuous real-time monitoring with the CardioNet device was not medically indicated in this case since off-line analysis with a patient activated device should be sufficient to identify symptomatic dysrhythmias without jeopardizing the patients safety. Immediate recognition and reporting of dysrhythmias through a call center provided by CardioNet real-time mobile telemetry remains investigational in this circumstance and has not been shown to improve health outcomes compared to standard monitoring techniques. Accordingly, I have determined the device at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

A 43-year-old male enrollee has requested testing using Tc-99 SPECT scan (IgG sub-class), punch nerve biopsy for small nerve neuropathy and Valcyte for treatment of his medical condition. Findings:  The physician reviewer found that although a recent study by Donta and colleagues refers to finding abnormalities in SPECT scans of patients with chronic Lyme disease, the study included no controls from which to compare the subjects. There is a lack of other recent studies demonstrating that SPECT brain scanning is valuable in the setting of Lyme disease. Per the medical records, a Tc-99 SPECT scan (IgG sub-class) is not likely to help diagnose any condition involved in this patients case.  The requested punch nerve biopsy for small nerve neuropathy is not medically necessary based upon the documentation provided. Peripheral nerve biopsy is not needed to diagnose the uncommon involvement of these nerves in Lyme disease. The requested medication Valcyte is not medically necessary for treatment of the patients condition. Valcyte is an antiviral agent and has no efficacy against bacterial organisms such as Borrelia burgdorferi. Based upon the documentation provided, the patient does not present with a condition that will benefit from use of Valcyte. There is no evidence that this medication is clinically indicated in this patients case.  In conclusion, testing using Tc-99 SPECT scan (IgG sub-class), punch nerve biopsy for small nerve neuropathy and Valcyte are not medically necessary for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Afirma gene testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The testing requested utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, gene testing was likely to have been superior over other methods of evaluating this patient.   Final Result:  Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repetitive transcranial magnetic stimulation (TMS) for treatment of the enrollees depression. Findings: The physician reviewer found that although some preliminary positivism regarding the application of TMS therapy for the bipolar population can be found in the medical literature, the absence of well-controlled and adequately powered exploratory and confirmatory studies do not establish TMS as a treatment of bipolarity. Further, this patients records do not include a current psychiatric evaluation, progress notes or discharge summaries from the recent hospitalization and aftercare programming. Given the lack of documentation, the records do not support a diagnosis of bipolar disorder or major depressive disorder. All told, the requested repetitive TMS 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned

A 68-year-old male enrollee has requested a computed tomography angiography (CTA) heart scan for an evaluation of his atrial fibrillation. Findings:  Three physician reviewers found that the use of cardiovascular computed tomography is a well-established, appropriate use of this technology in this patient subset based on the most recent American College of Cardiology (ACC) guidelines. No other diagnostic test or procedure was likely to be as useful as CTA in this setting.
Appeal type: Experimental/Investigational
Decision: Overturned

A 52-year-old male enrollee has requested authorization for genetic testing for Kennedys disease for evaluation of his medical condition. Findings:  Three physician reviewers found that although this patients symptoms and clinical exam are suggestive of amyotrophic lateral sclerosis (ALS), Kennedys disease cannot be entirely excluded. It is imperative to determine the correct diagnosis for this patient as it could dramatically alter his prognosis and treatment. The literature above supports the use of genetic testing in this setting. Genetic testing for Kennedys disease is a well-accepted diagnostic tool, and it is indicated in this patients particular case and could alter his prognosis and ultimate treatment management.
Appeal type: Experimental/Investigational
Decision: Upheld

A 60-year-old female enrollee has requested transcranial magnetic stimulation (TMS) treatments for treatment of her behavioral health condition. Findings:  Three physician reviewers found that when diagnosing patients with treatment resistant depression, clinicians should identify risk factors associated with treatment resistance, including clinical subtypes of depression and medical or psychiatric co-morbidities that could affect the course of treatment (Gaynes and colleagues). This particular patient had co-morbidities of depression and OCD. The use of atypical anti-psychotics has been shown to have some efficacy as augmentation therapy in treatment resistant depression (TRD) and represent a standard alternative in this clinical settting. No evidence that such agents were tried prior to TMS has been provided. Currently, the efficacy in using TMS for psychiatric disorders such as OCD has not been established. The article by Slotemas and colleagues concluded that TMS is not recommended for the treatment of patients with OCD.
Appeal type: Medical Necessity
Decision: Upheld

A 63-year-old female enrollee has requested Crestor for treatment of her hyperlipidemia.  Findings:  The physician reviewer found that the medical literature support a need to treat elevated LDL cholesterol in patients with known coronary artery disease and to set LDL cholesterol goals as secondary prevention measures. Statin medications are the most widely used for this purpose and improve not only LDL levels but act as anti-inflammatory agents. The data demonstrate fewer vascular events in those under treatment. Cholesterol goals can be achieved with many agents including atorvastatin (Lipitor) and rosuvastatin (Crestor). The incidence of side effects including elevation of liver enzymes and myositis are similar with both agents. Statins are a reasonable option for secondary prevention in this patient. However, there is no data to suggest that either of these agents would provide a superior outcome. Thus, the approval of Lipitor is consistent with the American Heart Association (AHA) and American College of Cardiology (ACC) guidelines. All told, the requested Crestor is not supported as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee has requested speech therapy for treatment of the enrollees Aspergers syndrome.  Findings:  The physician reviewer found that speech therapy is medically necessary for this patient with autism spectrum disorder-pervasive developmental disorder not otherwise specified. On evaluation, this patient displayed significant social skills deficits and a history of pragmatic language delays. Language skills make a significant difference in the ability of children to control their environment especially with social skills deficits (Volmar and Weisner). Goldstein reviewed the available communication interventions for patients with autism in peer-reviewed research articles published over the past 20 years. The authors reported that the evidence supports the claim that effective interventions exist to teach communication skills to children with autism. The goal of teaching social skills is to improve the quality of life. Research and clinical experience have also demonstrated that social skills impairments affect optimal functioning in all areas of life for patients with PDD-NOS (Countryman). This patient has a history of poor peer interaction and significant social and emotional deficits. All told, this patient will benefit from speech therapy emphasizing pragmatic speech and social interaction skills. In addition, a thorough speech evaluation with emphasis on standardized testing for pragmatics is recommended.