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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Vest chest wall oscillation device for treatment of her bronchiectasis. The physician reviewer found that as every patient with pneumonia has a local bronchiectastic reaction in the area of pneumonia, there is a lack of documentation that diffuse bronchiectasis is this patients primary lung disease. However, even if this patient has diffuse bronchiectasis, the Vest chest wall oscillation device would not be medically necessary. The Vest Airway Clearance System (Vest) is a high frequency chest wall device for chest physical therapy and has been available since 1988. The device has been studied most frequently in patients with cystic fibrosis where daily chest physical therapy is considered the standard of care. However, there has been no documented superiority of the Vest over routine chest physical therapy in any disease entity where the long-term endpoint of the prospective clinical trial were clinically significant outcome endpoints such as fewer hospitalizations for pulmonary infections, decrease in length of stay of a hospitalization, or decrease in the progression of pulmonary disease. All told, the Vest chest wall oscillation device was not and is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the device at issue was not and 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 and pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Cologuard gene test.Findings: Two of the three physician reviewers found that conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Toward this end, the efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against what is viewed as the gold standard, optical colonoscopy. Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers and a non-DNA immunochemical assay for human hemoglobin. Given the low sensitivity of Cologuard in detecting adenomas, the superior efficacy of the services at issue has not been established. The submitted records do not support that more effective conventional screening strategies were contraindicated in this patients case. Thus, the Cologuard test provided to the patient was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine, with subspecialty certification in gastroenterology, 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 occipital nerve block therapy. Current medical literature supports the use of greater occipital nerve blocks for the treatment of chronic migraine headaches. In a systematic review and meta-analysis, researchers report that peripheral nerve blocks have long been used to reduce the frequency and severity of migraines, and that greater occipital nerve blocking should be recommended for use in patients with migraines. Researchers note that greater occipital nerve block intervention can significantly alleviate pain and reduce the number of headache days and medication consumption. In this case, the patient has chronic migraines and had failed multiple medications. Given that the patient reported relief with peripheral nerve blocks in the past, the service at issue was likely to have been more effective than other therapies in reducing this patients migraine pain scores, and the frequency and duration of his migraines. Therefore, occipital nerve block therapy was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the occipital nerve block therapy at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1 and 3 are board certified in neurology and are actively practicing. Physician reviewer 2 is board certified in neurology with sub-specialty certification in vascular neurology 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

A 49-year-old female enrollee has requested Nexium 40 mg twice per day for the treatment of her medical condition. Findings:  The physician reviewer found that proton pump inhibitors (PPIs) are the main stay and backbone of therapy for the management of patients with gastroesophageal reflux disease (GERD) and Barretts esophagus. Reducing the acidity of gastric juice ameliorates reflux symptoms and allows esophagitis to heal. Most patients require a once a day dose of a PPI such as Nexium, Protonix, or Prevacid, etc. However, in a small group of patients a twice a day regimen is required. Clinical trials are lacking with respect to the efficacy of proton-pump inhibitors as a twice-daily regimen for refractory symptoms, though such dosing is sometimes used in practice. In this particular patient, the medical records do not document that she has tried and failed a trial of Nexium 40 mg once per day for 30 days. The Health Plans requirement that the patient undergo a documented trial of Nexium 40 mg once per day for 30 days prior to seeking coverage for Nexium 40 mg twice a day is medically appropriate and consistent with standards of practice.
Appeal type: Medical Necessity
Decision: Overturned

A 52-year-old male enrollee has requested Humira for the treatment of his psoriatic arthritis. Findings:  The physician reviewer found that Humira is Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis and has been associated with dramatic improvement in both skin and joint involvement, as in this patient. There is ample evidence in the medical literature for the therapeutic benefit of this drug in psoriatic arthritis. Fitzgerald writes that, As a result of numerous large, well-conducted, randomized controlled trials, there is now accumulating evidence that anti-TNF treatments are effective in controlling peripheral arthritis symptoms and signs, improving quality of life, and preventing radiologic progression. Overall, the scientific validity of Humira in this setting has been established and its use is consistent with the standard of care in rheumatology.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-month-old male enrollee has requested for a Synagis injection for treatment of the enrollees respiratory distress syndrome with respiratory failure.    Findings:  The physician reviewer found that The American Academy of Pediatrics (AAP) guidelines published in 2003 recommend palivizumab for RSV prophylaxis for premature infants born at 32 to 35 weeks gestation who are six months old or younger at the start of RSV season if they possess two additional risk factors. These factors include school-age siblings, day care attendance, airway abnormalities, neuromuscular disease and/or exposure to environmental air pollutants.Horn and Stout analyzed retrospective data from 304 infants less than one year of age with bronchiolitis or RSV pneumonia admitted to the hospital. Data were subdivided by gestational age and compared, looking at rates of intubation and intensive care unit admission, as well as length of stay. They found that infants less than one year of age born at 33 to 35 weeks gestation fared worse than those born more prematurely over all measures. They concluded that premature birth during this critical period of lung development may result in significant alteration in lung function and physiology.Finally, there are other risk factors that not only increase the chance of morbidity, but also mortality from RSV disease in infants up to twelve months of age. The most striking of these is a birth weight less than 2500 grams. An infant with a birth weight between 1500 and 2500 grams is five times more likely to die from RSV infection than an infant with a birth weight greater than or equal to 2500 grams.
Appeal type: Medical Necessity
Decision: Overturned

A 30-year-old female enrollee has requested ondansetron tablets for treatment of her nausea and vomiting.  Findings:  The physician reviewer found that chronic pancreatitis is characterized by upper abdominal pain in the epigastric region.  This pain can be exacerbated by eating, and associated symptoms include nausea, vomiting, weight loss, oily stools, and malabsorption.  Ondansetron reduces the activity of the vagus nerve, which deactivates the vomiting center in the medulla oblongata and blocks serotonin receptors in the chemoreceptor trigger zone.  Ondansetron is a treatment option in this clinical setting.  This patient has persistent nausea due to chronic pancreatitis.  The current medical evidence supports the requested medication in this patients case.  All told, ondansetron tablets are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

The parent of an eight-month-old female has requested follow-up and testing at an infant development clinic for treatment of the patient who was born at 29 weeks gestation.  Findings:  The physician reviewer found that infants born prematurely and those born with extremely low birth weight are at risk for a number of difficulties including nutrition and growth problems, cerebral palsy and other motor difficulties, mental retardation and other neurodevelopmental disabilities, behavioral problems including ADHD, and sensory impairments. According to one source, up to 50% of infants born weighing less than 1500 grams and up to 60-70% of infants born weighing less than 1000 grams have problems at school, (e.g., learning difficulties, failing grades, special education requirements, etc.). They have a greater chance of experiencing language delay, visual-perceptual problems, and problems with attention and behavior. Per the authors of Handbook of Neonatal Intensive Care, Under ideal conditions parents of all NICU infants should be offered comprehensive, coordinated, developmentally based, family-oriented follow-up for their child through infancy and childhood. In a Cochrane review of the effectiveness of early developmental intervention post-discharge from hospital for preterm infants on motor and cognitive development, the authors concluded that early intervention programs for preterm infants have a positive influence on cognitive outcomes in the short (0-2 years) and medium (3-less than 5 years) term.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility services for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has been in the inpatient rehabilitation setting for a prolonged period of time without making significant functional progress.  She had essentially plateaued with respect to function at requiring maximum to total assistance for most of her self-care and mobility.  Going forward, the patient would not be expected to make significant functional progress in a reasonably predictable and timely fashion.  The medical literature does not support the necessity of this intervention in the absence of demonstrated and expected functional progress.  All told, skilled nursing facility services were not and are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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

An enrollee has requested reimbursement for a chromoendoscopy.  Chromoendoscopy has been demonstrated to be superior to standard alternatives for localization of dysplasia in randomized trials. Per the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for inflammatory bowel disease, chromoendoscopy allows better characterization of visible lesions as endoscopically resectable or unresectable, and chromoendoscopy with targeted biopsies is the preferred surveillance technique to maximize dysplasia detection. Per the joint guideline from the ASGE and American Gastroenterological Association (AGA), chromoendoscopy is suggested rather than white-light colonoscopy. When there is evidence of dysplasia, the data support surveillance using chromoendoscopy with high-definition colonoscopy. This patient was found to have dysplasia on biopsies of the colon. She underwent surveillance biopsies for dysplasia with chromoendoscopy, which was consistent the current guidelines. Therefore, the chromoendoscopy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the chromoendoscopy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 subspecialty 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: Medical Necessity
Decision: Upheld

A fifty-three year-old female with elevated blood pressure, as well as heart palpitations, headache, and nose bleeds is requesting reimbursement for 24-hour ambulatory blood pressure monitoring (ABPM).Reviewers Findings:  The reviewing physician found that ABPM is not recommended as the initial or mandatory first step in the diagnosis of routine systemic hypertension.  The reviewing physician found that the Health Plan denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test DecisionDx-UM. Cytogenetic testing of choroidal melanoma is an established method of laboratory evaluation of melanomas. The medical literature supports the routine use of the DecisionDx-UM to adjust a patients surveillance based on the genetic profile of the tumor. In addition, the counseling and eligibility for clinical treatment trials is based heavily on the tumor genetic profile. Given this support, the gene test DecisionDx-UM was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three of the three physician reviewers found the gene test DecisionDx-UM was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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 ophthalmology 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: Overturned

An enrollees parent has requested authorization and coverage for Nutropin AQ Nuspin. The current medical evidence supports growth hormone therapy for patients with idiopathic short stature. This patient has a pre-treatment height that was a few standard deviations below the mean and a diagnosis of idiopathic short stature. The records document suboptimal growth for her pubertal development. She has a history of anorexia nervosa, which can affect linear growth. Of note, even when her weight has improved, her height remained a few standard deviations below the mean, which indicates abnormal linear growth. This patient had a normal work-up to exclude other cause of short stature. Therefore, Nutropin AQ Nuspin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 71-year-old male with idiopathic pulmonary fibrosis (IPF). Based upon the submitted medical records, the patient has IPF, cor pulmonale, atrial fibrillation. The patient is being treated with Actimmune injections, azathioprine and prednisone for his pulmonary fibrosis. In February 2004, the patients provider indicated the patients decline in lung function might be due to the reduction of the dose of prednisone or a paradoxical response to Actimmune. In April 2004, the patients provider stated that the decline in lung function might be due to progression of disease rather than a paradoxical response to Actimmune. The patient was then referred to another provider who recommended continuation of Actimmune treatment. Pulmonary function tests performed on 1/7/04 showed TLC 49% and DLCO 28%. Pulmonary function tests performed on 4/9/04 showed TLC 50% and DLCO 28%. Clinically, the patient complained of worsening respiratory symptoms in that interval. CT scan of the chest performed on 4/12/04 showed stable pulmonary fibrosis when compared to the 8/28/03 study. The Health Plan has denied authorization and coverage for Actimmune on the basis that it is not medically necessary for treatment of the patients condition.A study by Ziesche and colleagues enrolled 18 patients and studied the effects of Actimmune in the treatment of IPF. The results showed statistically significant improvement in total lung capacity, forced vital capacity, and PaO2 in patients treated with thrice weekly Actimmune. The results were promising and led to a phase III trial using Actimmune versus placebo in the treatment of IPF. However, subsequent studies found Actimmune provided little or no benefit for patients with IPF. Kalra, et al. concluded that Actimmune did not benefit IPF patients. Davies, et al. found little evidence to support use of Actimmune. Honoreet, et al. found that Actimmune can cause respiratory failure in IPF patients. Furthermore, the most comprehensive and clinically relevant study of the role of Actimmune in the treatment of IPF (Raghu, et al.) found that treatment with Actimmune did not affect progression-free survival, pulmonary function or quality of life. Thus, use of Actimmune is not medically indicated for treatment of the patients IPF given the lack of proven benefit and some evidence for harm.Based upon the information set forth above, I have determined that the requested therapy is not medically necessary for the treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

A 52-year-old female enrollee has requested Bystolic 2.5mg for the treatment of her hypertension and tachycardia. Findings:  The physician reviewer found that for this patient a beta blocker is a good clinical choice. The patient was tried on two beta blockers with symptoms related to the medications. A formulary beta blocker was recommended by the Health Plan. A trial of a different beta blocker is a reasonable clinical strategy. There is no evidence demonstrating that Bystolic is clinically superior to the formulary beta blockers. The alternative recommended by the Health Plan is medically reasonable and appropriate in this setting.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 7-year-old female enrollee has requested desmopressin 0.2 mg for treatment of the enrollees nocturnal enuresis. Findings:  The physician reviewer found the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Due to the potential side effects of medications, a physician and family should make an effort to use non-medicinal treatment modalities prior to starting medicinal treatment. In the case of nocturnal enuresis, primary treatment methods should include voiding charts, bladder training, reward charts and enuresis alarms. If some or all of these methods fail, then medicinal treatment should be considered. In the absence of documentation demonstrating failure of non-medicinal treatment, the requested medication is not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld

A forty-eight year-old male with stage T4 pancreatic cancer is requesting coverage of stereotactic radiosurgery.  Reviewers Findings:  The reviewing physician found that there is no scientific evidence demonstrating that stereotactic radiosurgery will result in any improvement in the patients condition.  The Health Plan denial was upheld.