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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for food allergy testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee has been diagnosed with irritable bowel syndrome.Findings:  The use of food specific IgG level testing is unproven, does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. The medical literature shows that food specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. In addition, IgG4 is increased in patients who successfully underwent oral immunotherapy for milk or peanut allergy. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food specific IgE in the serum. These tests are widely available. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food specific IgE is used in the diagnosis of IgE mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE mediated allergy upon subsequent challenge with a 90-95% predictive accuracy. Thus, food specific IgG should not be used as a tool to diagnose food allergy and the positive food should not be eliminated from the diet based upon results from these tests. In sum, food allergy testing (IgG) provided on 10/26/17 was not likely to have been superior over the available standard testing for the evaluation of this patients medical condition.  Final Result: All three reviewers have determined that the services at issue were 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:  All three reviewers are board certified in allergy and immunology 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: Overturned

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement 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. For dimension 1, the patient was at serious risk of harm (score 4) due to significant recent aggression with poor judgment and insight. The provider noted that the patients behavioral issues included property destruction, impulsivity, and substance use. The patient indicated that she has thought about harming the person responsible for her admission to the RTC. For dimension 2, the patient demonstrated serious functional impairment (score 4) given her conflict with parents, recent school failures, physical altercations, and disregard for rules. For dimension 3, the patient has significant comorbidities (score 3) considering her coexisting substance abuse and mental illness. The patient reported that she likes to drink alcohol while on social media. For dimension 4, the patients recovery environment was moderately stressful (score 3) due to her parents difficulties with substance abuse and her history of abuse. In addition, the patients recovery environment provided limited support (score 3) due to her parents struggles to consistently participate in family therapy and their difficulty with co-parenting. For dimension 5, the patient has exhibited limited response and resiliency to treatment (score 3) given her inability to follow treatment recommendations and departure from the RTC against the recommendation of her providers. For dimension 6, the patient was non-collaborative in treatment (score 4) due to a lack of participation and elopement from the RTC against the recommendation of her providers. These findings give the patient a composite score of 24, which is consistent with medically monitored residence-based services. Per CALOCUS, the patient qualifies for Level 5B intermediate stay medically monitored residence-based services due to impulsivity, family conflict, academic failures, co-occurring substance abuse and mental illness, and parents struggles to respond to the patients needs. The typical length of stay at this level is up to 60 days. All told, the RTC services were medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in detection of small cancers and decrease in biopsies, especially in women with extremely or heterogeneously dense tissue.  In sum, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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 diagnostic radiology 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: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for fetal sex and sex chromosome aneuploidy panel options for Harmony Prenatal Test. Findings:  Three physician reviewers found that fetal aneuploidy screening is supported for pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.  Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes.  This patients age places her at increased risk for all fetal chromosomal abnormalities.  Currently, the screening test of choice is cell-free DNA testing.  Sex chromosome abnormalities, such as Turners syndrome, include significant associated medical morbidities.  In sum, fetal sex and sex chromosome aneuploidy panel options for Harmony Prenatal Test provided were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 2 of 3 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 physician reviewers are board certified in obstetrics and gynecology 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: Medical Necessity
Decision: Upheld

A 53-year-old male enrollee requested authorization and coverage of the medication Provigil.  The health plan denied this request indicting the Provigil is not medically necessary for treatment of the enrollees Parkinsons disease.One physician reviewer performed a medical necessity Independent Medical Review.  The physician reviewer upheld the health plans denial on the basis that the requested medication is not medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested electric tumor treatment fields (TTF) therapy using Optune plus transducers for treatment of the enrollees recurrent glioblastoma multiforme.  Two physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The TTF system, which has been approved by the U.S. Food and Drug Administration (FDA), is a portable device that delivers low-intensity, intermediate frequency electric fields via non-invasive means. The study by Stupp and colleagues included more than 200 patients randomized to either TTF or chemotherapy. The authors concluded that there was no difference in progression-free survival, but quality of life and toxicity favored TTF therapy. In addition, the National Comprehensive Cancer Network (NCCN) guidelines include TTF therapy as a treatment option for glioblastoma. Based on the medical literature and clinical documentation submitted, electric TTF therapy using Optune plus transducers is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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: One reviewer is board certified in medical oncology and is actively practicing. One reviewer is board certified in radiation oncology and is actively practicing.  One reviewer is board certified in neurological surgery 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: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:    An enrollee has requested Harvoni for 12 weeks for the treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines indicate that the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The guidelines support Harvoni for 12 weeks for patients with hepatitis C, genotype 6 infection who have failed prior treatment with peg-interferon and ribavirin.  All told, Harvoni for 12 weeks is medically indicated 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 57-year-old male enrollee has requested biofeedback for treatment of his pain.  Findings:  Two physician reviewers found that the article by Newton-John and colleagues was submitted in support of this appeal.  However, these authors noted no significant difference between cognitive behavioral treatment and electromyographic biofeedback. The article by Glombiewski and colleagues noted that biofeedback did not lead to improved outcome of psychological intervention.  Cognitive behavioral treatment was noted to be effective.  This patient has had cognitive behavioral treatment, and this article indicates that biofeedback would not improve efficacy.  In summary, the current medical evidence does not show that the requested biofeedback is likely to be more efficacious than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

A 59-year-old female has requested coverage for continued inpatient occupational therapy and physical therapy from a specific date and forward for treatment of the enrollees multiple injuries. Findings:  The physician reviewer found that the submitted medical records fail to demonstrate the medical necessity of the services at issue in this patients case.  Based upon the submitted documentation, the patient could have been safely discharged to a lower level of care as of the date in question.  Per the medical records, the patient is able to ambulate and transfer at a stand by assist level.   Per the current medical literature, patients who are able to transfer and ambulate at a stand by assist level are appropriate for community discharge.  This patient is able to take oral pain medications.  As on the date in question she had reached a level of function that did not require daily skilled therapy.  In this clinical setting, continued improvement in function can be achieved with continued exercise without daily supervision from a skilled therapist.  The medical records do not demonstrate any daily skilled nursing needs.  All told, continued inpatient occupational therapy and physical therapy from the date in question and forward was not and is not medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation with a pain management specialist. Findings:  The physician reviewer found that guidelines for prescribing opioids for non-cancer pain state that Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. The American Society of Interventional Pain Physicians (ASIPP) guidelines state that if there is any indication of abuse, misuse, lack of analgesia, lack of activity, adverse effects, or aberrant behavior, the physician must taper the drug therapy and discontinue. In this case, the patient has chronic back pain with a history of previous fusion. He has been treated by pain management providers in the past, but he has a history of more than one inconsistent urine drug screen. The provider documented that the patient has been managed on high-dose opioid therapy as a temporary measure. The CDC guidelines recommend tapering opioid therapy in patients who have demonstrated non-compliance with their opioid agreements. The ASIPP guidelines recommend referrals to pain specialists for chronic non-cancer pain unresponsive to conservative management or in cases where high-dose opioid therapy is required. The CDC and ASIPP guidelines support that a referral to a pain specialist is appropriate for this patient to provide non-pharmacological alternatives in light of the inconsistent urinalysis results. Based on the current national guidelines and medical records reviewed, the requested consultation with a pain management specialist is medically necessary for 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 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.
Appeal type: Medical Necessity
Decision: Upheld

The patient is a 44-year-old male with a chronic history of low back and right flank pain. Since 1995 he has had various tests for these complaints including an IVP, CT scan, nuclear medicine renal scan, barium enema, endoscopy and MRI. The only positive exam was the MRI of the lumbar spine showing mild degenerative disc disease. The patient has been evaluated by specialists in gastroenterology, urology, orthopedic surgery and behavioral medicine. The patient has also received acupuncture for the pain. He is a bodybuilder and has a history of steroid use. The patient is requesting a PET scan for further evaluation of his pain.The submitted clinical information provides no indication for a PET scan. PET scan is neither a screening test nor is it indicated for pain of unknown etiology. No CMS (Centers for Medicare and Medicaid Services) or NOPR (National Oncologic PET Registry) indications for PET scan include pain. Therefore, I have determined the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 45-year-old female with low back pain. The patient underwent NSAIDs, chiropractic, and a conservative treatment program without relief. In June and July 2004, the patient underwent sacroiliac and lumbar facet joint injections. The Health Plan indicates these injections were not medically necessary for treatment of the patients medical condition. Facet joint injections were appropriate on a diagnostic and therapeutic basis in this case. The submitted clinical evidence demonstrates the patient failed conservative treatment including NSAIDs, and chiropractic. The injections at issue were medically appropriate and indicated in this patient who had failed multiple pain management modalities and was experiencing debilitating pain. Therefore, I have determined that the injections at issue were medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira and Ribasphere for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety; the medication is U.S. Food and Drug Administration-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al; Poordad, et al; Ferenci, et al). For these reasons, the requested treatment with Viekira Pak and Ribasphere is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition.  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 31-year-old female enrollee has requested Celebrex 200 mg twice per day for treatment of her spinal cord injury (SCI) at C3-4.  Findings:  The physician reviewer found that Celebrex 200 mg twice per day is not medically necessary for treatment of this patients SCI. The medical literature states that non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for osteoarthritis at the lowest dose for the shortest period in patients with moderate to severe pain to prevent or lower the risk of complications associated with cardiovascular disease and gastrointestinal (GI) distress. Celebrex is a cox-2 inhibitor NSAID. The scientific data supports use of cox-2 inhibitor NSAIDs for patients with a history of gastroesophageal reflux disease (GERD), or those at increased risk for GI ulcers or bleeding. Laine evaluated the role of cox-2 inhibitors and reported that these agents reduce the rate of endoscopic ulcers as compared to traditional NSAIDs. Brown and colleagues performed a retrospective study to assess the relative effectiveness for prevention of NSAID-induced GI toxicity. The authors found that cox-2 specific inhibitor NSAIDs are better at preventing GI complications than non-selective NSAIDs. However, the medical records provided for review do not document the length of time this patient has been on Celebrex. Additionally, there is no documentation of an increased GI risk requiring a cox-2 inhibitor in lieu of a standard NSAID. All told, the medical records do not support the medical necessity of the requested Celebrex 200 mg twice per day.
Appeal type: Medical Necessity
Decision: Upheld

The representative of a deceased 44-year-old male enrollee has requested for insulin potentiation therapy (IPT) for treatment of the enrollees esophageal cancer.  Findings:  The physician reviewer found that there is no reliable scientific data to support the use of IPT in the treatment of cancer. At this time, IPT has no known clinical benefit. According to the American Cancer Society, there are concerns about using lower doses of chemotherapy drugs. When chemotherapy drugs are tested in clinical trials, their effects are carefully monitored to learn which dose will best balance the need to kill cancer cells with the goal of keeping the side effects at a tolerable level. There is no evidence that chemotherapy at a fraction of the recommended and tested dose can produce the same effect as the full dose if used with insulin. The American Cancer Society also noted that despite supporters' claims that IPT has been well researched, scientific studies that show safety and effectiveness, have not been published.