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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Arthrotec 75/200 (diclofenac 75 mg and misoprostol 200 mg) Findings:  The physician reviewer found that : the request for Arthrotec 75/200 (diclofenac 75 mg and misoprostol 200 mg) is not medically necessary for treatment of the patients medical condition. Misoprostol is a synthetic prostaglandin that is used to reduce the risk of stomach ulcers in patients treated with nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the patient does not have a diagnosis of gastroesophageal reflux disease, gastric ulcers or intolerance of a nonselective NSAID medication. Lastly, Arthrotec is a compound drug that includes convenience packaging of more than one medication. For these reasons, the request for Arthrotec has not been established as medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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: Upheld

A 61-year-old male enrollee has requested authorization and coverage for BioniCare knee device (joint nerve stimulator).  The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees knee pain.  Findings:  Three physician reviewers found that the patient has osteoarthritis of the knee.  The medical records noted that the patient reported a three-year history of right knee pain.  Per the submitted documentation, this pain was not associated with an injury.  The patient has requested coverage for a BioniCare knee device (joint nerve stimulator).  The Health Plan has denied this request and reported that the requested device is investigational for the treatment of this patient.  The patient is appealing this denial.  The superior efficacy of the requested device has not been established.  The current medical evidence does not provide support for the use of the requested BioniCare knee device (joint nerve stimulator).  There is a lack of evidence supporting the requested device in this patients case.  The evidence in published peer-reviewed literature does not support the efficacy of transcutaneous electrical joint stimulation devices for any indication.   Therefore, the requested BioniCare knee device (joint nerve stimulator) is not likely to be more beneficial than other treatment alternatives in this patients case.
Appeal type: Experimental/Investigational
Decision: Overturned

A 70-year-old female enrollee has requested right sacroiliac joint arthrography and injections for the treatment of her chronic lower back pain. Findings:  Three physician reviewers found that this patient has persistent buttock pain after multiple procedures. The physician wished to assess whether the sacroiliac joint could be the source of the pain. The use of sacroiliac joint injection/arthrography in this setting is an appropriate diagnostic technique to help rule out the sacroiliac joint as the cause of the problem.
Appeal type: Medical Necessity
Decision: Overturned

The parent of a one-year-old male enrollee has requested for speech therapy and physical therapy for treatment of the enrollees Down syndrome.  Findings:  The physician reviewer found that the American Academy of Pediatrics recommends that pediatricians consider speech therapy in patients with Down syndrome. The general consensus among providers is that speech therapy is necessary to improve the overall level of communication in these patients who seldom maximize language beyond a second grade skill level as adults. the American Academy of Pediatrics also recommends physical therapy for patients with Down syndrome. As noted by Ulrich and colleagues in their controlled study, young patients with Down syndrome who received treadmill training coupled with intensive PT attained walking at a much earlier age than the non-PT group.
Appeal type: Medical Necessity
Decision: Overturned

The patient is a 38-year-old female with a history of chronic pain due to costochondritis. The patient indicates that she has been treated by a pain management specialist for the past few years. It appears the patients medications include trazadone, Duragesic, and Vicodin. The notes from the patients pain management specialist indicate that the patients primary care physician is uncomfortable with prescribing triplicates. The patient has requested authorization and coverage for continuation of her pain management treatment plan.Based upon the submitted records, it appears the patients pain has been under control with medication. Generally when this is accomplished the pain management specialist can discharge the patient back to the primary care physician. It is typically within a primary care physicians scope of practice to continue writing prescriptions for these medications once the patient is stable. However, in this case it appears the patients primary care physician does not feel it is within the scope of her practice as she is not comfortable with prescribing triplicates. In any event, the patients pain management treatment plan has been successful and continuation of the treatment plan is medically indicated. Therefore, I have determined that the requested services are medically necessary for treatment of the patients medical condition. The Health Plans denial should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

A 31-year-old female enrollee has requested Botox injections for treatment of her migraine headaches.  Findings:  Two physician reviewers found that in the past, the patient has tried multiple medications for her headaches.  Despite the use of these medications, the patients headaches have not been well-controlled.  More recently, the patient has tried a course of Botox.  After this therapy, the patient was reported to have an improvement in the severity and frequency of her headaches.  Although Botox is not a first-line therapy for migraine headaches, there is adequate literature supporting its use for refractory cases.   In this particular case, the patient has failed multiple first-line headache therapies, either due to ineffectiveness or side effects.  In addition, the patient had a documented effect with Botox. All told, Botox injections are likely to be the most efficacious treatment alternative for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the advantage afforded the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone. Final Result: Two 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 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: Upheld

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for immunoglobulin G (IgG) testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. Food-specific IgG level testing does not predict true food hypersensitivity and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) levels for foods and skin testing. IgE immunoassays are in vitro assays which are used to identify food-specific IgE in the serum. 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 percent. 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. In conclusion, the IgG testing was not likely to be more effective than other available methods of evaluating this patient. Final Result: The reviewers determined that found 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: Physician reviewers 1, 2 and 3 are board certified in allergy and immunology 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient rehabilitation services for treatment of her medical condition.  Findings: The physician reviewer found that the medical literature supports the medical necessity of the requested inpatient rehabilitation services for further treatment of this patients condition. Her provider has certified that she requires skilled nursing or rehabilitation services at least five days a week and the services require professionally trained personnel. Also, the patient needs to be able to participate for three hours a day in rehabilitation. The patient is making good progress at home and has been able to participate in three hours of rehabilitation a day. However, the records indicate that the patient has severe behavior problems secondary to hypoxic encephalopathy which is impeding her care. Further, her diabetes is not stable and she has some breakdown of skin . Additional breakdown of the skin could cause a severe wound which could lead to sepsis, and close blood glucose monitoring is indicated. Thus, the requested inpatient rehabilitation would give her the best chance to treat her behaviors by instituting a proper medicine regimen and providing intensive treatment by nursing and social services.  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 physician 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: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Anser IFX testing for evaluation of the enrollees Crohns disease. Findings: All three physician reviewers found that in this case, Anser IFX was ordered to determine Remicade level and whether antibodies to Remicade were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to Remicade, nor have clear Remicade levels been established. Studies have found that anti-Remicade antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. Final Result: The 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: 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: Medical Necessity
Decision: Upheld

A 65-year-old male enrollee has requested Tarceva (to be used in conjunction with Gemzar) for the treatment of his metastatic pancreatic cancer. Findings:  The physician reviewer found that the provider has indicated that the treatment plan was to initially treat the patient with gemcitabine/oxaliplatin followed by gemcitabine/Tarceva. There is evidence supporting the use of the gemcitabine/oxaliplatin combination. Gemcitabine chemotherapy has been the standard of care for metastatic pancreatic cancer since it provides a survival benefit compared to best supportive care in clinical trials. The benefit is modest, with median survival of six months. Gemcitabine has been combined with other chemotherapeutic drugs with mixed results. Recently, the FDA approved Tarceva as first-line therapy in combination with gemcitabine based on a randomized clinical trial where 569 patients received either gemcitabine alone or in combination with Tarceva.  The latter treatment arm resulted in a modest improvement in survival that was statistically significant (6.24 versus 5.91 months). Although the clinical trial showed a statistically significant increase in overall survival, there is a debate among practicing oncologists regarding whether this is clinically meaningful in light of the toxicities of Tarceva. Furthermore, this trial involved the use of Tarceva and gemcitabine as first-line therapy, whereas this patient has been treated with gemcitabine/oxaliplatin. All told, there is inadequate support for the combination of Tarceva and gemcitabine in this previously treated patient to demonstrate its medical necessity.
Appeal type: Medical Necessity
Decision: Overturned

The patient has requested authorization and coverage for bevacizumab 10 mg injections in combination with TAS-102. TAS-102 is a newer compound that has been demonstrated to improve overall survival in patients with refractory metastatic colon cancer when compared with placebo. Further study has shown that this positive response is further improved with the addition of Avastin. Researchers found that their findings suggest that the addition of bevacizumab to the chemotherapy regimen could be an efficient and safe treatment option for patients with metastatic colorectal cancer as second-line therapy and without increasing the risk of adverse event. This patient has metastatic colorectal cancer that has progressed despite treatment with FOLFOX with bevacizumab and FOLFIRI with bevacizumab. Given the support in the medical literature, the requested bevacizumab 10 mg injections in combination with TAS-102 are medically necessary for 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 subspecialty certification in medical oncology 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 an 18-year-old female with approximately a four-year history of binging and purging with notable reduction in body weight from a high of 137 pounds to 96.4 pounds by the point of admission to residential treatment in August 2005.  The patient had also engaged in some minor self-abusive behaviors of cutting on herself on two occasions and was noted as quite obsessed about her boyfriend. Her admission lab work revealed evidence of mild malnutrition, dehydration, and hypokalemia. During her stay, she was treated with a number of psychotherapies as well as Prozac 20 mg, which she tolerated well. The patient engaged fully in the various therapies and appeared to have no problem complying with the dietary demands of the program.  All told, she was seen as having sustained a good deal of improvement by the end of her stay in October 2005, such that she weighed 108.2 pounds, with zero body image distortion.  At issue in this case is whether the residential treatment services from September 2005 through October 2005 were medically necessary for treatment of the patients medical condition.There is no question that the patient suffered from bulimia nervosa.  However, all of the progress notes in September 2005 indicate the patient had experienced significant improvement by that point. The issue of zero body image distortion is also noted in several of the progress notes during the period at issue. The patient was eventually stepped down to a continuation program affiliated with the residential program; there is no evidence that such a step-down was not medically appropriate as of September 2005.  Accordingly, I have determined the services at issue were not medically necessary for treatment of the patients medical condition. The Health Plans denial should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

A 62-year-old male enrollee has requested computed tomography (CT) angiogram for evaluation of his shortness of breath and abnormal stress test. Findings:  Two physician reviewers found that based on the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) guidelines, given the patients exercise tolerance and level of activity, following a normal exercise stress imaging test, the additional diagnostic procedure was not indicated. The records indicate the patients stress ECHO provided physiologic information suggestive of normal resting function and considerable cardiac reserve. This demonstrates important data regarding the competence of the coronary circulation to increase flow and oxygen delivery as the needs dictate. However, the patients medical condition did not require additional evaluation with the diagnostic procedure at issue.
Appeal type: Medical Necessity
Decision: Upheld

The parent of a 17-year-old male enrollee requested substance abuse residential treatment center (RTC) for treatment of the enrollees substance abuse treatment.  Findings:  The physician reviewer found that substance abuse RTC services were not medically necessary for treatment of the patients medical condition. On admission to residential treatment, the patient was not in withdrawals and was not at risk for imminent withdrawals. There was no evidence of risk of danger to self or others. There was no psychotic ideation and the patient was medically and psychiatrically stable. The patients psychiatric condition did not require 24-hour monitoring in a restrictive level of care. He demonstrated motivation and insight into the risks involved in his behavior, expressed a desire to change, and his family was supportive. Although he continued to report passive suicidal ideation, this is a hallmark feature of many psychiatric illnesses and does not constitute a rationale to admit or keep a patient in a residential setting without the presence of concomitant aggressive behavior, intent, planning, substance abuse, or withdrawal. In sum, the patient did not require 24-hour supervision in a residential setting and he does not meet the medical necessity criteria for residential treatment.
Appeal type: Medical Necessity
Decision: Upheld

A 32-year-old male enrollee has requested laparoscopic adjustable gastric banding (Lap-band) surgery for treatment of his obesity.  Findings:  The physician reviewer found that with a BMI of 38 and comorbid conditions including degenerative joint disease, the patient is likely to benefit from Lap-band surgery. However, there is no evidence the patient has obtained psychological clearance for weight loss surgery. Given the patients significant history of mental health disorders, the patient must be formally evaluated in order to determine if he is an appropriate candidate for weight loss surgery.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Rasuvo. The Health Plan denied the request and reported the requested medication is not medically necessary for the treatment of this patient. At issue in this case is whether Rasuvo is medically necessary for the treatment of the patients medical condition. Researchers reported that orally administered methotrexate is well absorbed in patients with inflammatory bowel disease, including those with severe small bowel disease or resection. In this case, injectable methotrexate is being used in combination with Stelara. The patient has intolerance to sulfasalazine due to GI side effects. Other therapy has included prednisone, Humira, and Rasuvo. There is no evidence the patient has taken oral methotrexate or has severe GI disease. The medical evidence does not support the requested medication in this clinical setting. Therefore, Rasuvo is not medically necessary for the treatment of this patient. 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 allergy and immunology and internal medicine with sub-specialty certification in rheumatology 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

The parent of a five-year-old female enrollee has requested Genotropin growth hormone therapy for the treatment of the enrollees Turners syndrome. Findings:  The physician reviewer found that the patients diagnosis is FDA approved for growth hormone therapy, and the literature is replete with trials indicating the benefits in adult height which otherwise end up around the 4.5 feet range. Growth hormone therapy is medically indicated. The accompanied letter of appeal from the Pfizer Bridge program adequately hits the relevant points and references.