Persius/imr-appeals huggingface dataset:
Summary Reviewer 2 
 
A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation 
therapy (PBT). The Health Insurer has denied this request and reported that the requested service is 
investigational for the treatment of the enrollees locally advanced esophagus cancer. The physician 
reviewer found that PBT is not likely to be more beneficial for treatment of the patients condition than 
any available standard therapy.
Summary Reviewer 3


A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found 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 infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Based on the medical literature, Anser IFX testing performed on 9/04/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer  
 
The patient is a 28-year-old male who presented to his provider on 9/2/22. The patient has 
requested reimbursement for magnetic resonance (e.g. proton) imaging, any joint of lower 
extremity, without contrast material, on 9/21/22. The Health insurer has denied this request and 
reported that the services at issue were not medically necessary for the evaluation of this patient.  
The physician reviewer found that the submitted documentation supports the medical necessity 
of a portion of the services at issue. In this case, the patient had left ankle and right knee pain for 
years that did not respond to conservative treatment. Notes dated 9/2/22 reported left posterior 
tibial tendon tenderness and a positive Tinels sign, suggesting impingement. Subsequent MRI 
imaging of the ankle did not show structural issues. The patient reported that the MRIs resulted 
in a diagnosis of Tarsal Tunnel syndrome and referral for EMG. An EMG was conducted by a 
neurologist that confirmed the diagnosis. Notes dated 9/2/22 also reported severe right knee 
medial joint line tenderness and patellofemoral pain. MRI of the right knee revealed a deep root 
tear of the meniscus requiring arthroscopy. While the American College of Radiology (ACR) notes 
that MRI is usually not appropriate in the setting of chronic ankle or knee pain without prior x-
rays, given this patients multi-year history of prolonged and unexplained ankle and knee pain, 
the services at issue were medically indicated. Therefore, magnetic resonance imaging of the 
right knee and the left ankle were medically necessary for the evaluation of this patient.
Summary Reviewer 1 
 
The parent of a 13-year-old female enrollee has requested reimbursement for needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20. The 
Health Insurer has denied this request and reported that the services at issue were 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that the medical evidence supports the services at issue in this clinical setting. This 
patient was being treated for adolescent idiopathic scoliosis. She underwent a thoracoscopic 
anterior spinal tethering. This procedure involved a high risk of significant complications. The 
use of electromyographical monitoring has been found beneficial to help prevent further injury 
during this procedure. Therefore, needle electromyography (EMG) of anal or urethral sphincter, 
any technique; needle electromyography, each extremity; and electroencephalogram 
performed on 6/10/20 was likely to have been more beneficial than any available standard 
therapy.
Summary Reviewer 3


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that CMA is increasingly utilized for genetic testing of individuals with unexplained developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  CMA offers a much higher diagnostic yield for genetic testing of patients with unexplained developmental delay/intellectual disability, autism spectrum disorder, or multiple congenital anomalies than the previous standard testing with G-banded karyotype, primarily because of its higher sensitivity for submicroscopic deletions and duplications.  Available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  Given that the standard of care is now CMA, the FirstStepDx Plus chromosomal microarray was likely to have been of greater benefit than other methods of evaluation.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 1

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The medical evidence does not support the use of intravenous, intramuscular, or subcutaneous immune globulin as a treatment to prevent recurrent spontaneous abortion in pregnant women. The American College of Obstetricians and Gynecologists does not support the requested services for the treatment of this patient. The use of intravenous immune globulin for pregnancy loss prevention has not been demonstrated by large scale, prospective clinical trials to have superior outcomes compared to existing therapies. Therefore, immune globulin injection (Gamunex-C), 500 mg is not likely to be of greater benefit than other treatment options.
Summary Reviewer 2

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is limited high-quality data on the management of recurrent pregnancy loss. Currently, therapeutic recommendations are largely based upon clinical experience and data from observational studies. This patients provider seeks to treat her recurrent pregnancy loss thought to be of autoimmune nature with intravenous immune globulin (IVIG). The studies cited by the provider are observational and pre-date current systematic reviews. Systematic reviews have consistently found no beneficial effect of immunotherapy for treatment of recurrent pregnancy loss. Wong and colleagues performed a systematic review of 20 trials of high-quality. The authors noted that immunotherapy did not result in a statistically significant improvement in live births compared to untreated controls. Treatment with intravenous immune globulin was included in this study. In sum, immune globulin injection (Gamunex-C), 500 mg is not likely to be superior over other available treatment options.
Summary Reviewer 3

A 63-year-old female has requested reimbursement for Anser ADA testing provided on 4/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management of ulcerative colitis. Patients being treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature. These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, the clinical literature has not established the superior efficacy of Anser ADA testing performed on 4/25/16.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 2

The patient is a 19-year-old female with short stature, congenital heart disease, multiple minor malformations, and borderline intellectual disability. A specific diagnosis could not be recognized.  Chromosomal microarray was performed to investigate the etiology of the patients medical issues, in order to direct the patients medical care more specifically. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement and reported the services at issue were investigational for the evaluation of the patients medical condition.  Array-based comparative genomic hybridization (CGH, or chromosomal microarray) has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies.  Formerly, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; however, currently it is considered a first-line investigation.  The yield of this test is approximately 8 to 17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The cited references indicate that this test has become an important and mainstream tool in the practice of clinical genetics.  As early as 2007, its utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability.  More recently, its clinical utility has been confirmed in a study by Henderson and colleagues where 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management (including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation).  Medical literature has shown that microarray results affect clinical management, at rates, which are similar to other genetic testing. Given the potential to influence management, microarray is an appropriate test to perform in this clinical scenario. Accordingly, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more effective for the evaluation of this patients medical condition than the other available modalities.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 

The patient is a 59-year-old female with listed diagnoses of inflammatory polyarthropathy, osteoarthritis and fibromyalgia. She has been treated with multiple medications, including prednisone, sulfasalazine, Humira, ibuprofen and Toradol. The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested medication in this clinical setting. This patient reports pain in her back, hands and feet, as well as multiple soft tissue areas. She has been treated with multiple medications to date, all of which have either resulted in side effects or a lack of response. The available medical records do not document objective findings to support the presence of an inflammatory arthritis. There is no documentation of synovitis on physical examination, nor is there documentation of radiologic studies with findings consistent with inflammatory disease. On the basis of this lack of documentation, the requested medication is not medically indicated. Additionally, there is a lack of evidence
supporting the use of H.P. Acthar Gel in fibromyalgia. Therefore, H.P. Acthar 80 unit/mL Gel is not medically necessary for the treatment of this patient.
Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal at any time, although he had recent passive suicidal ideation without intent to harm himself. With regards to functional status, the records support a score of 2. The patient has had some issues with level of function that were sporadic nature. He showed intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient does not have active medical problems or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient has had minimal prior treatment and was cooperative in the residential treatment center program at issue. In terms of acceptance and engagement, the records support a score of 2. The patient actively participated in therapy on admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 16.  This score correlates with intensive outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 11/16/17 through 1/04/18 was not medically necessary for the treatment of this patient.
Summary Reviewer 

The parent of a 16-month-old female enrollee has requested authorization and coverage for hourly pediatric nursing, 12 hours per day, seven days per week (S9123). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this medically fragile patient has a number of problems as a result of, and in addition to, her cloacal abnormalities, chronic kidney disease, and prematurity. The most important issue for her at this time, prior to completion of her reconstructive surgeries, is prevention of urinary tract infection and preservation of renal function. With the introduction of skilled nursing services, she has had no further significant urinary tract infections requiring parenteral antibiotics and hospitalization. She has been able to attend preschool to aid in her development and help her to catch up to her peers. The patients mother is the primary caregiver and has significantly modified her schedule in order to provide for the patients custodial needs. She does not have the necessary expertise, however, to provide for the patients skilled medical needs, including ostomy care and prevention of urinary tract infections. The requested skilled nursing services 12 hours daily 7 days per week are essential to this patients current health as well as to the future success of her reconstructive surgeries. Therefore, the requested hourly pediatric nursing, 12 hours per day, seven days per week (S9123), is medically necessary for the treatment of this patient.
Summary Reviewer 3

A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found the staging and classification of cutaneous melanoma has classically been described by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma testing is an assay of 31 genes in the cells of an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not known how the five-year DecisionDx-Melanoma testing data compares to the 10-year Balch data. Additionally, it is not clear if the DecisionDx-Melanoma classification can be used to make therapeutic decisions, such as whether to do a sentinel node and/or give adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.
Summary Reviewer 

The patient is a 26-year-old female with a history of an intensive care unit admission for alcoholic ketoacidosis. She had a history of depression and anxiety with poor compliance with medication. The physician reviewer found that based on the records, this patient met American Society of Addiction Medicine (ASAM) criteria for sub-acute substance abuse rehabilitation (ASAM 3.5) provided from 6/20/21 through 7/18/21. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. 

For dimension 1, acute intoxication or withdrawal potential, the patient had several episodes of withdrawal and experienced alcoholic ketoacidosis, alcohol hepatocyte injury, macrocytic anemia and physical withdrawal. After discharge from the inpatient hospital, she was stable enough to receive further medical detoxification at the level 3.5 residential treatment level of care.

For dimension 2, biomedical conditions, the patientas medical problems as cited in dimension 1 were stable enough to be treated at the 3.5 level of care.

For dimension 3, emotional, behavioral, or cognitive conditions, the patient had a history of anxiety and depression and had difficulty complying with medication on an outpatient basis. Her co-occurring anxiety and depression and need for supervision of medications meets ASAM 3.5 level of care criteria.

For dimension 4, readiness to change, the patient was ambivalent about residential treatment and thought it was ajust what her family wanteda, showing low insight and poor judgment and supporting the need for further structured treatment to enhance her willingness to change.

For dimension 5, relapse, continued use, continued problem potential, the patient had tried stopping on her own several times and had developed serious medical problems which could worsen and be potentially fatal outside of a structured 24-hour monitored treatment setting.  

For dimension 6, recovery environment, the patientas family works in the wine business and she would have been exposed to continuous use had she been discharged to her motheras home. The patient had no support for sobriety at her home in Colorado. She met 3.5 level of care on dimension 6.

Accordingly, sub-acute substance abuse rehabilitation (ASAM 3.5) provided from 6/20/21 through 7/18/21 was medically necessary for the treatment of this patient
Summary Reviewer 3

A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the automated nerve conduction studies in dispute performed during surgery are not supported in the peer-reviewed literature. Intraoperative monitoring utilizing automated nerve conduction testing on peripheral nerves during surgery was not indicated. There is a lack of support in the medical literature supporting nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. As such, the automated intraoperative nerve conduction studies were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that the medical literature supports breast tomosynthesis in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/30/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.