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

The patient has a history of Crohns disease.  There was concern for an increase in symptoms and a fecal calprotectin test was ordered. Three physician reviewers found that various studies have found that fecal calprotectin correlates with endoscopic findings of inflammation and serum markers of inflammation in Crohns disease. Further studies have found that fecal calprotectin is useful to assess disease activity in Crohns disease. The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease recommend fecal calprotectin to assess disease activity in patients with Crohns disease. In this case, the patient had symptoms of active Crohns disease, which should be addressed to prevent complications of Crohns disease. For these reasons, fecal calprotectin test at issue was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: The reviewers determined that the requested test was 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 overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing provided for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  The 3 physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The testing at issue does not eliminate the need for serial PSAs and rectal examinations to detect changes in the patients medical condition. In addition, the provider noted that the patients increase in PSA is not likely related to prostate cancer. For the reasons provided, the gene testing provided was not 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 testing at issue was 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: Physician reviewer number one is board certified in urology 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 urology 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 urology 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

Physician 1: The patient is a 52-year-old female with arthritis and degenerative disc disease who complains of chronic low back pain. Neither medications nor epidermal injections have relieved her symptoms.  The patient is requesting authorization for an inferential stimulation unit for pain management.  The Heath Plan denied her request based upon a determination that the device is experimental/investigational for the treatment of lower back pain.Inferential stimulation therapy is generally regarded as experimental for the management of pain syndromes. There is little in the peer-reviewed literature to support its use for chronic low back pain and it is not considered to be within the standard of care for management of that condition.  Reports of symptomatic relief are considered anecdotal and have not been substantiated through peer-reviewed, placebo-controlled trials. Therefore, I have determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 2: The patient is a 52-year-old female with chronic low back pain due to degenerative disc disease and arthritis. She has tried various treatment modalities, and has found the inferential stimulation unit most effectively manages her pain.  The patients provider has requested authorization for an interferential stimulation unit. The Health Plan has denied authorization citing the investigational nature of the device.Interferential stimulation units have not been shown to demonstrate superior efficacy as compared to more conventional treatment such as Transcutaneous Nerve Stimulation (TNS).  The requested unit is investigational for the treatment of chronic back pain.  Based on the fact that a similar effect may be achieved with a TNS unit, I have determined that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 52-year-old female with significant lower back pain due to a work-related injury. Her provider recommends the inferential stimulation unit to manage her pain as other approaches have failed to provide sustained relief.  The patient has requested authorization for an interferential stimulation unit.  The Health Plan considers the device experimental/investigational and has denied her request.As indicated in the records provided for review, the patient has tried both medical management and epidural injections, but has not achieved satisfactory pain relief. Based upon her positive response to interferential therapy, a three-month trial with the inferential stimulation unit is appropriate. On these facts, it is likely that the requested device is more beneficial for the treatment of her pain than standard treatment modalities. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for genetic cancer screening. The enrollee has a family history of cancer. Her physician ordered a genetic screening test because of her family history. The provider believes the results will help guide treatment recommendations. Individuals with a personal or family history of cancer may carry a mutation that increases the risk for other types of cancer. These individuals are appropriate candidates for genetics counseling and testing. There is no evidence submitted that this enrollee had any assessment or any genetic counseling prior to undergoing genetic testing. This enrollee is at increased risk for breast cancer, but she is not at high risk for the types of cancer that are included in the panel for cancer screening.Final Result: Two of the three reviewers determined that the requested service was not likely to have been more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in clinical cytogenetics and clinical genetics 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

A 58-year-old female enrollee has requested authorization and coverage for surgery to resolve bruising, lumping and skin discoloration at the sclerotherapy injection site.  Findings:  The physician reviewer found that the records indicate that this patient developed known complications of spider vein sclerotherapy. The sclerotherapy procedure is designed to create inflammation within the spider vein in order for it to shrivel and collapse. However, the bodys response to the inflammatory process is unpredictable. Further, the complication described in this case causes no dysfunction and is not considered an abnormal condition. All told, the requested procedure is not expected to significantly improve the patients function or appearance.
Appeal type: Experimental/Investigational
Decision: Overturned

The mother of a 16-year-old female enrollee has requested for Botox injections for treatment of the enrollees migraine headaches. Findings:  Two physician reviewers found that Botox is a well-accepted and standard of care medication amongst headache specialists for patients failing multiple medications in multiple classes of prophylactic drugs.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a three-year-old male enrollee requested a Courtney Bed, fully enclosed hospital grade bed, as a medical necessity of the enrollee, who has global developmental delay.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  The Courtney Bed is a fully enclosed hospital grade bed which is likely to be of benefit in this patients case.  Any type of open bed, hospital grade or community grade, poses a risk to this patient.  He has limited safe mobility, yet is highly active and lacks safety awareness and protective reflexes.  The patients current sleeping situation, with the mattress inside the crib frame but on the floor, is unacceptable because of the risk of entrapment and collapse of the crib.  A toddler bed is an open system from which he can fall or injure himself while trying to stand.  The ideal system encases him in such a way that he cannot get entrapped, become injured by the frame, or fall out.  The Courtney Bed provides a sleep environment that is safe for this patient.  All told, the requested Courtney Bed, fully enclosed hospital grade bed, is medically indicated in this patients case.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Otezla 10 mg/20 mg/30 mg titration pack  55 tablets for 28 days, then Otezla 30 mg twice daily. Findings:  The physician reviewer found that Otezla (apremilast) is a phosphodiesterase-4 (PDE4) inhibitor, which decreases PDE4 activity, which in turn reduces the inflammatory process thought to be associated with psoriasis and psoriatic arthritis. According to Nassim and colleagues, apremilast has shown therapeutic efficacy when the use of standardized treatments such as systemic corticosteroids or immunosuppressive agents have not been effective or practical or have caused excessive side effects. Otezla can be helpful in settings where traditional treatments do not work well enough. In this case, the patient has a history of plantar erosive lichen planus as well as oral/vulvovaginal erosive lichen planus being treated with immunosuppression and PUVA soaks. She has had to be on disability from her job due to her condition. Thus, the patient has severe disease. The patient has been refractory to traditional therapies, topical steroids and tacrolimus as well as more aggressive therapies, like IVIG. There is sufficient support for the requested medication in this clinical setting. Thus, the requested Otezla 10 mg/20 mg/30 mg titration pack  55 tablets for 28 days, then Otezla 30 mg twice daily is medically necessary for the treatment of the patients medical condition.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 reimbursement for residential treatment provided 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. The patient was experiencing mild post-acute withdrawal symptoms.  He was not a danger to himself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable.  He was motivated and appeared to be working the program. He had a sponsor.  He was cooperative and participating in his treatment plan.  No new problems had arisen.  Although he continued to struggle with his emotions and required further treatment to help develop coping skills, he could have been stepped down to an ambulatory level of care, such as intensive outpatient program level of care, and pursued further psychological support as well as relapse prevention and education. Final Result: The reviewers 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: Upheld

A 68-year-old male enrollee has requested coverage for X-Stop (spinal distraction device) surgery. The Health Plan has denied this request indicating that the surgery at issue was and is considered investigational for treatment of the enrollees low back pain radiating to the bilateral extremities.  Findings:  Three physician reviewers found that the patient has a long history of back pain and neurogenic claudication. His symptoms are improved with rest or sitting. He has not had success with medications, physical therapy, osteopathic care, chiropractic care, acupuncture, or injections. His magnetic resonance imaging (MRI) shows a broad-based disc protrusion at L2-3 as well as stenosis at L3-4 and L4-5. There is also anterolisthesis at L3-4. The patients provider performed bilateral decompression at L2-S1, discectomy L2-3, and insertion of interspinous distraction device (X-Stop) at L2-3, 3-4, and 4-5. The patient has requested reimbursement for the X-Stop placement and the Health Plan has denied this request as investigational in this clinical setting. This patient clearly has symptomatic spinal stenosis at L3-4 and L4-5 with neurogenic claudication as demonstrated on MRI scan. At issue is the use of the X-Stop device. The FDA has approved and restricted its use in only two levels in well selected patients. However, the North American Spine Society (NASS) indicates that use of X-Stop is not supported in the peer reviewed medical literature as durable, safe, effective, and providing equivalent or superior outcomes when compared to standard therapies. Without large, long-term studies establishing the safety and effectiveness the X-Stop is not considered within the standard of care (Kondrashov, et al). Currently, the FDA requirements to determine the durability and potential side effects of the device include 5- and 7-year studies and these are ongoing.
Appeal type: Medical Necessity
Decision: Overturned

This patient is a 36-year-old female with symptomatic mammary hypertrophy (back, neck, and shoulder pain as well as headache and intertrigo).  She sought consultation with a board certified plastic surgeon who recommended a bilateral reduction mammoplasty to relieve her symptoms. The patient had previously tried physical therapy with only short-term relief. The Health Plan has denied authorization for the requested surgery citing the small volume of breast tissue to be removed as not consistent with medical necessity.The submitted materials include clinical records and digital photographs of the patient. The evidence provided demonstrates large breasts consistent with the symptoms stated.  The proposed surgery is very likely to result in resolution of the patients symptoms. Based upon the information provided, the patient meets ASPS recommended guidelines for a bilateral reduction mammoplasty. As such, I have determined that the requested surgery is medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay testing. Findings: The physician reviewer found that in the peer-reviewed medical literature, there is a paucity of medical literature demonstrating that molecular markers are useful in treatment determination and prognosis in patients with colon cancer. The American Society of Clinical Oncology (ASCO) guidelines do not address use of this assay. In addition, the National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend the use of multi-gene assays, such as the Oncotype DX assay, to determine adjuvant therapy. Accordingly, the Oncotype Dx Colon Cancer Assay testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Oncotype Dx Colon Cancer Assay testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of the three reviewers determined that the testing at issue was 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned

A 28-year-old male enrollee has requested transcranial magnetic stimulation for treatment of his treatment resistant depression.  Findings:  Two physician reviewers found that the efficacy and safety of TMS is well documented in the literature and NeuroStar TMS system has received Food and Drug Administration (FDA) approval. TMS has demonstrated efficacy in the treatment of major depressive disorder (MDD)(Janicak and colleagues). In addition, Demitrack and Thase report that TMS is safer and better tolerated than many other pharmacotherapeutic options and ECT. In fact the authors suggest that ECT is associated with risks and cognitive side effects. Schutters study found TMS to be an alternative treatment for patients suffering from MDD, especially for those who do not tolerate the side effects associated with regular pharmacological treatment. Given this patients clinical history and lack of response to a litany of psychopharmacologic interventions, TMS is likely to be more beneficial than any other available standard therapy for treatment of his condition.
Appeal type: Medical Necessity
Decision: Upheld

A 28-year-old male enrollee has requested Norco for treatment of his pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence does not support Norco in this clinical setting.  Per the medical records, this patient has been on Norco long-term without documentation of improved function.  He has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  High-dose and short-acting opiates may also cause adverse outcomes. Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Norco is not medically indicated for the treatment of this patient.