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

A 56-year-old female enrollee has requested continuous azithromycin (Zithromax) for the treatment of her bronchiolitis obliterans/constrictive bronchiolitis. Findings:  The physician reviewer found that there are significant long-term complications of chronic steroids, and other anti-inflammatory agents should be tried. As macrolide antibiotics such as Zithromax have been shown to be helpful in eosinophilic bronchiolitis, a six-month trial of Zithromax is medically appropriate. As discussed in review papers, the macrolides have been shown to have significant anti-inflammatory effects. These have had demonstrated efficacy in panbronchiolitis and other chronic inflammatory conditions of the lungs. Given this patient's clinical condition as well as her lack of adequate response to steroid treatment, an additional six-month trial of Zithromax is medically necessary and indicated at this time, and is supported by the literature for this use. If after the six-month trial period, there is documentation of improvement in FVC-FEV1 and/or FRC, the medication should be continued.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female has requested approval for magnetic resonance imaging (MRI) of the ankle and foot for evaluation of her acute venous thrombosis of the vessels of the distal lower extremity.   Findings:  The physician reviewer found that based on review of the available records, this patient has symptoms suggestive of severe back pain extending down into the right foot. These symptoms may represent a more serious condition than what would be identified on an isolated MRI of the foot, especially given the patients past history. The patient should be thoroughly evaluated by an orthopedic surgeon who could evaluate the patients back pain and foot pain. However, the clinical indication for use of MRI in evaluating this patients medical condition at this time is not supported by the records provided for review.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not reporting post-acute withdrawal symptoms.  The patient had not received a detoxification protocol.  The patient did report ongoing cravings, depression, and anxiety.  The patient was medically and psychiatrically stable.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  There were no reported attempts to treat her at a lower level of care, such as intensive outpatient programming.   Although she continued to struggle with her emotions and required further treatment to help her develop and solidify coping skills, she no longer required the structured environment of a residential setting and could have continued at a lower level of care.  Therefore, residential treatment services were not medically indicated for the treatment of this patient.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 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 50-year-old female enrollee has requested Botox injections for treatment of her intractable migraine headaches. Findings:  Three physician reviewers found that this patient has been diagnosed with intractable migraines. She has failed a variety of preventives in the past, and thus her condition can be considered refractory. The literature regarding Botox shows it to be well-tolerated, generally without systemic side effects, and with adverse effects that are generally mild to at most moderate. The most recent and largest studies show benefit in patients with chronic migraine, even with ongoing medication overuse. Thus, there is adequate evidence that Botox can be useful in a subset of migraine patients such as this patient. Botox is more likely than standard treatment to be of benefit to this patient, and should be covered for ongoing treatment of her chronic migraine.
Appeal type: Experimental/Investigational
Decision: Upheld

A 63-year-old female enrollee has requested authorization and coverage for a trial with a percutaneous trigeminal nerve stimulator for treatment of the enrollees right sided trigeminal neuralgia.  Findings:  Three physician reviewers found that the patient has a long history consistent with trigeminal neuralgia. The patient has been treated with Tegretol, however experienced negative side effects and was then placed on Neurontin, which provided only partial relief. She then underwent stereotactic radiosurgery. The patient experienced significant pain relief following the surgery, but began to have recurrent pain recently. The patients Neurontin was then increased, which produced symptoms of ataxia and vomiting. The patient was again tried on Tegretol and also underwent a trial of pregabalin, but experienced significant side effects. The patient has requested authorization for a trial with a percutaneous trigeminal nerve stimulator which the health plan denied.  Initial studies suggested that refractory pain, secondary to chronic migraines and trigeminal neuralgia, may respond to peripheral nerve stimulation. Trigeminal neuralgia is often refractory to treatment and although peripheral nerve stimulation has been used to treat occipital neuralgia, its efficacy in controlling facial trigeminal neuralgia or postherpetic neuralgia is unknown. Further clinical studies are indicated to evaluate the long-term efficacy of trigeminal nerve stimulation for the treatment of trigeminal neuralgia and to determine the optimal array and implantation technique to use in this treatment (Royster and Crumbley). Therefore, the requested service remains of unproven efficacy for treatment of the patients condition and the Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 56-year-old female enrollee has requested for a cardiac CT angiography for evaluation of her coronary arteries. Findings:  Three physician reviewers found that the American College of Cardiology (ACC) has published guidelines regarding the appropriate use of cardiac CT angiography. This patient falls in the asymptomatic group.  Per Table 2 of the ACC guidelines, Detection of CAD: Asymptomatic (Without Chest Pain Syndrome) cardiac CTA is inappropriate for low and moderate risk patients such as this patient. A high LDL is not as yet an appropriate indication for cardiac CT angiography.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aimovig 70 mg/ml auto-injector. Aimovig (erenumab) is a calcitonin gene-related peptide monoclonal antibody (CGRP mAb). CGRP mAbs are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. Medical literature shows a phase 2 randomized, double-blind placebo-controlled study of erenumab for adults aged 18-65 years with chronic migraines. Medical literature shows that erenumab 70 mg and 140 mg reduced the number of monthly migraine days, with a safety profile similar to placebo. Medical literature shows, Clinical judgment may result in an emerging treatment being added to one or more established treatments. If initiating treatment with an antiCGRP mAb in a patient already on a preventive treatment, since the risk of drugmAb interactions is minimal or nonexistent, it is appropriate to add the mAb to the existing regimen and make no other changes until the effectiveness of the mAb is determined. In this case, the patient has a history of chronic migraines that have not responded to oral preventive medications. In this setting, it is appropriate to initiate treatment with an antiCGRP mAb. Therefore, Aimovig 70 mg/ml auto-injector, 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 neurology 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: The spouse of the deceased enrollee has requested reimbursement for the gene testing for evaluation of his pancreatic endocrine carcinoma. Findings:  Two physician reviewers found that molecular profiling of an individuals cancer cells is an assay of genomic and molecular abnormalities. The goal of this assay would be to identify a target at which a specific treatment could then be offered. Although of scientific interest, as yet there is a lack of convincing evidence that the assay adds to the decision making ability to improve patient outcome. There are a variety of non-randomized studies exploring the value of molecular profiling but have not been convincing as to the superior efficacy of these assays.  Researchers noted the ongoing research but reported the serious limitations of these studies. A recent randomized trial, did not demonstrate significant clinical benefit when choosing therapy based on molecular targets. As such, there is a lack of robust medical studies to indicate the clinical benefit of this assay in this clinical setting. Final Result: The reviewers determined that the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for omeprazole 40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients abdominal pain. The submitted documentation does not support the medical necessity of the requested medication. American College of Gastroenterology guidelines for gastroesophageal reflux disease (GERD) recommends proton pump inhibitor (PPI) therapy for patients with GERD. Researchers found there to be no difference in the multiple formulary PPIs, such as those attempted by this patient, which include omeprazole, lansoprazole, rabeprazole, and pantoprazole in the control and healing of GERD. Clinical guidelines for dyspepsia, also characterized by abdominal pain, recommend an attempt of proton pump inhibitor therapy. However, the requested prescription omeprazole is not supported as superior to over-the-counter omeprazole or other PPI alternatives. For this reason, omeprazole 40 mg is not 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: Medical Necessity
Decision: Overturned

A 60-year-old male is requesting the medication Aggrenox for stroke prevention. Findings:  The physician reviewer found that Aggrenox has been shown to be an effective medication for preventing strokes.  Although the official study is still pending, in a recent study, cited above, Aggrenox was shown that it has comparable results to Plavix.  Given that the patient has tolerated Aggrenox and has not had any events while taking it, it is medically reasonable to continue with this medication.  Given his successful history with the medication, it is clinically appropriate for the patient to continue treatment with Aggrenox and not discontinue this successful treatment with a trial of another medication.
Appeal type: Medical Necessity
Decision: Upheld

Findings:  The physician reviewer found that The patient has requested authorization and coverage for use of an electric mobility scooter (Group 1 power operated vehicle). The records document that this patient has a history of multiple chronic health conditions including diabetes mellitus, obesity, and arthropathy. On physical examination, the patient has normal range of motion, coordination, and strength in all limbs. The provider noted that the patient is able to stand for up to 15 minutes and walk more than 40 feet. Overall, the patient does not have any documented impairments that preclude use of a mobility device such as a walker with a seat to accomplish mobility related activities of daily living in the home, and a manual wheelchair to perform community based instrumental activities of daily living. Patients with chronic health conditions such as hypertension, heart disease, obesity, and diabetes mellitus generally benefit from exercise such as regular walking or self-propelling a manual wheelchair (Forhan and Gill; Heymsfield and Wadden; Kahan; Kushner). Reliance on motorized mobility when ambulation or manual wheelchair use are feasible can have detrimental effects on cardiovascular health and expected longevity. Therefore, the requested use of an electric mobility scooter (Group 1 power operated vehicle) is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Oxycontin for treatment of the enrollees chronic intractable pain syndrome.  Findings: The physician reviewer found that based on the medical literature and the presented clinical records, Oxycontin 60 mg twice per day has not been established as medically necessary. The requested dosage and quantity are excessive in light of the patients condition and in addition to the medication regimen. Such doses and quantity are only indicated for malignant pain. The medical records shows the patient has chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation or joint disease is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study by Mafi and colleagues, there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report by Karppinen and colleagues which states that Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic [low back pain] LBP. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP Furthermore, these therapies work best in a multidisciplinary rehabilitation context. There are a variety of anticonvulsants and anti-depressants considered adjunctive to pain management therapy. In addition, high dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Short-acting opiates are likely to cause adverse outcomes. Therefore, Oxycontin 60 mg twice per day is not medically necessary for treatment of the patients medical condition. An appropriate tapering regimen should be implemented to avoid possible untoward effects associated with abrupt cessation of the patients current regimen.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-specialty 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: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  The 3 physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the diagnostic procedure 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 50-year-old male enrollee has requested Provigil 600mg per day for treatment of his bipolar disorder, attention deficit/hyperactivity disorder and obstructive sleep apnea. Findings:  Three physician reviewers found that this patient has had significant overall improvement with this dose of Provigil.  There is documentation that this medication dose has had positive improvement, without adverse effects from the medication. A significant fact in this case is that nearly all of the medications that the patient is currently prescribed are above FDA recommended maximum doses.  He appears to be an individual that does not respond to standard FDA recommended medication doses. This may be due to a faster than average metabolism. Psychiatric medications are often utilized at doses that are above those recommended by the FDA, as the response of individual patients to the same drug administered in the same dose varies considerably.  In this patients case, Provigil 600mg is likely to be more beneficial than other available standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene panel testing. Findings:  Three physician reviewers found that this patient underwent expanded BRCA analysis testing, which is considered a standard of care in patients diagnosed with breast cancer before the age of 50, regardless of family history. Her family history also raises the suspicion of an inherited tendency for malignancy. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing is now considered a standard of care. Information regarding whether a patient carries a mutation may guide treatment decision making. Therefore, gene panel testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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.