Persius/imr-appeals huggingface dataset:
Summary  
The patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that 
the patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The 
patient has requested authorization and coverage for PBRT. The Health Insurer has denied this 
request and reported that the requested service is not medically necessary for the treatment of this 
patient. This denial is the subject of this appeal and determination. The physician reviewer found 
that the submitted documentation does not support the medical necessity of the requested service 
Proton beam has unique properties compared to standard photon or x-ray beam in its ability to 
deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered 
radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard 
photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe 
toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the 
setting of localized prostate cancer, there has not been a demonstrable clinically significant 
improvement in either quality of life or reduction of high-grade toxicities. Studies in current 
medical literature have not demonstrated a significant difference in overall survival nor normal 
tissue toxicities over photon beam in the treatment of prostate cancer. These data question the 
utility of proton beam radiation particularly for patients with localized disease. There are ongoing 
prospective trials investigating the potential benefits in disease outcomes and toxicities, however, 
no definite benefit has been demonstrated for proton beam at this time. While proton therapy may 
be medically indicated in some cases of unusual anatomy or in cases of re-irradiation of adjacent 
tissues, this is not the case for this particular patient. In this clinical setting, given this patients 
medical history and the nature of his prostate cancer diagnosis, the requested service is not 
medically indicated. Therefore, PBRT is not medically necessary for the treatment of this patient.
Summary Reviewer 1

A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found the current medical evidence does not support the requested services in this clinical setting.  Per the records, this patient has received only a single set of diagnostic lumbar medial branch blocks. Manchikanti and colleagues noted the evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. Additionally, the literature supports the use of a second set of diagnostic medial branch blocks. In this patients case, the pain relief did not exceed 75%, and a second set of diagnostic medial branch blocks was not performed. Therefore, the requested spine nerve treatment is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 


A 43-year-old male enrollee has requested reimbursement for a continuous positive airway pressure (CPAP) device provided on 2/9/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the clinical indication for CPAP device includes the requirement of documentation that the patient is compliant and is utilizing the CPAP device for at least four hours a night for at least 70% of the nights for a 30 day period. The patient noted he was not using CPAP because of seasonal allergies. There is a lack of documentation demonstrating that the patient utilized the device at issue for a 30 day period. Given the lack of documentation demonstrating compliance, CPAP was not medically necessary for treatment of the patients medical condition. Given the above reasons, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 


A 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure. The physician reviewer found that infection of a penile implant can cause complications from scarring after the penile implant is removed. Although a few studies with a small numbers of patients have shown that penile implants can be done in an outpatient setting, most providers prefer to continue preoperative antibiotics for at least 24 hours. The American Urological Associations (AUA) guideline for management of erectile dysfunction states, These antibiotics are administered before the incision is made and usually are continued for 24 to 48 hours postoperatively. The AUA best practice statement for antimicrobial prophylaxis in urologic surgery states, Although there are no [randomized controlled trials] RCTs regarding antimicrobial prophylaxis for insertion of penile prostheses, meta-analyses of mesh hernia repair 100 and orthopedic surgery 101 confirm that antimicrobial prophylaxis is beneficial when foreign material is implanted. A prolonged course of antimicrobials has been used by many practitioners following penile prosthesis insertion, but evidence from the orthopedic literature suggests that prophylaxis for 24 hours or less is adequate. In this case, there is a lack of documentation to support the medical necessity for inpatient care. Most patients who undergo penile prosthesis implantation can be discharged within 24 hours of presentation. The patient can be provided with perioperative antibiotics while on observation status without the need for inpatient stay. As such, the request for inpatient admission is not medically necessary for treatment of the patients medical condition. Therefore, the requested service is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1


A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. 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 services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient was at a significant risk from sudden cardiac death. He benefited from risk reduction with the wearable cardioverter defibrillator provided on 11/5/14. An increase in the risk of sudden cardiac death, and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. This patient was at risk for sudden cardiac death while awaiting improvement in left ventricular systolic function prior to consideration of a permanent ICD. Given the above, the wearable cardioverter defibrillator provided on 11/5/14 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 




The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment provided from 6/16/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition The physician reviewer found that the residential treatment provided from 6/16/16 forward was not and is not medically necessary for treatment of the patients medical condition. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient qualifies for Level Four, intensive integrated services without 24-hour psychiatric monitoring. Specifically, this level of care would include placements such as group homes or foster care. This level qualifies him for treatment by a child psychiatrist and nurse as well as individual and family therapy. Support services should also be provided. Specifically, in Dimension I, risk of harm, he scores as some risk of harm. Dimension II, functional status, he qualifies as serious functional impairment. Dimension III, co-morbidity developmental, medical, substance use and psychiatric, he qualifies as major co-morbidity. In Dimension IV, recovery environment, he scores as minimally stressful environment as his material needs are met without significant cause for concern. He also has a highly supportive environment, as the documentation notes he has access to a private school, tutors, and therapists. In Dimension V, resiliency and treatment history, he has shown poor resiliency and poor response to treatment. In Dimension VI, treatment acceptance and engagement, he has shown an obstructive engagement, as he was ambivalent, avoidant or distrustful in his relationship with clinicians and other care providers. However, his parents showed an optimal acceptance and engagement in his treatment. Given the above, the RTC level of care as of 6/16/16 was not and is not medically necessary for treatment of the patients medical condition.Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. The 
Health Insurer has denied this request and reported that the services at issue were investigational 
for the evaluation of the enrollees medical condition. The physician reviewer found that as noted 
by  Marion  and  colleagues,  chromoendoscopy  is  supported  as  superior  to  alternatives  for 
localization  of  dysplasia  in  randomized  trials.  Per  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  American  Gastroenterological  Association  guidelines,  Dye  spray 
chromoendoscopy...should be considered in all persons with colonic inflammatory bowel disease 
undergoing surveillance colonoscopy, particularly if a standard definition endoscope is used or if 
there is a history of dysplasia. The patient has had a colon polyp (of the serrated type) in the 
past, and aside from that, warrants surveillance biopsies for dysplasia given the diagnosis of 
ulcerative colitis. Per the guidelines cited above, surveillance colonoscopies should be performed 
using  chromoendoscopy  when  possible.  Therefore,  colorectal  cancer  screening  using 
chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22 was likely 
to have been more beneficial than any available standard therapy.
Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, the superior effectiveness of DecisionDx-Melanoma testing performed on 1/03/17 and transfer of the laboratory specimen has not been established in this patients case. 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 61-year-old male with persistent, symptomatic atrial fibrillation with multiple 
hospital visits for chemical cardioversion. The patient has requested authorization and coverage 
for hybrid convergent ablation treatment of atrial fibrillation (CPT 33266). The physician reviewer 
found  that  the  hybrid  convergent  procedure  has  superior  effectiveness  compared  with 
endocardial-only ablation in patients with advanced atrial fibrillation. This was demonstrated in 
the CONVERGE trial, a multicenter, randomized clinical trial which also showed a significantly 
higher number of patients in the hybrid convergent arm remaining free from cardioversion at 18 
months follow-up. This was also associated with an acceptable safety profile. The cumulative 
experience with the convergent procedure is now greater than 10,000 patients to date and has 
an established position in managing atrial fibrillation. Therefore, hybrid convergent ablation 
treatment of atrial fibrillation (CPT 33266) is medically necessary for treatment of the patients 
medical condition.
Summary Reviewer 3

The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the use of Rituxan in this case is not likely to be more beneficial than the available standard therapy. According to the 2019 American College of Rheumatology/Arthritis Foundation guideline for the treatment of juvenile idiopathic arthritis, biologic medications available to treat children with juvenile idiopathic arthritis include Actemra, Enbrel, Humira, and Orencia after failure of standard DMARD therapy. According to the Rituxan prescribing information, it is indicated for the treatment of rheumatoid arthritis in combination with methotrexate in adult patients with moderately-to-severely active rheumatoid arthritis who have had an inadequate response to one or more tumor necrosis factor antagonist therapies. This patient has failed a single biologic therapy according to the medical records. There are other options that are considered a standard of care in this case, including Orencia intravenous or subcutaneous, Actemra intravenous or subcutaneous, or Enbrel. These medications are indicated for juvenile idiopathic arthritis.  There is no data available to suggest that this patient would respond more to Rituxan as opposed to the biologic medications that are approved for juvenile idiopathic arthritis. Thus, Rituxan is not likely to be more beneficial than other available standard therapy.
Summary Reviewer 

The patient is a nine-year-old female. The patient has requested reimbursement for neuropsychological testing performed from 1/18/20 through 8/13/20. 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 the services at issue. Neuropsychological testing indicated that the patient had a complex combination of ADHD combined subtype, non-verbal learning disorders in math and reading, dysgraphia/dyspraxia, and dysthymia with symptoms of anxiety and depression. The patientas symptoms were interfering with her social, academic and family functioning. She was noted to be at risk of social isolation, peer rejection and bullying. The neuropsychological testing and school evaluations that were performed were the only means by which the patientas complex combination of conditions could be clarified, and appropriate intervention instituted. Therefore, neuropsychological testing performed from 1/18/20 through 8/13/20 was medically necessary for the evaluation of this patient.
Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  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 according to 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 noted 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 breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 7/25/16 was likely to have been more effective than 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.
Summary  
The patient is a 39-year-old female with a history of large breasts, low back pain, rheumatoid 
arthritis, spinal stenosis, degenerative disease, and herniated disc. The patient underwent breast 
reduction surgery on 9/12/22. The Health Insurer has denied the service at issue as not medically 
necessary for the treatment of the patients medical condition. This denial is the subject of this 
appeal and determination. The physician reviewer found that the American Society of Plastic 
Surgeons (ASPS) guidelines state that reduction mammaplasty should be performed based on 
documentation of the severity of the symptoms of macromastia and its impact on health-related 
quality of life. The guidelines indicate that reduction mammaplasty may be performed if at least 
two of the following quality-of-life signs are present: chronic breast pain due to breast weight, 
intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, 
thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial 
plexus compression syndrome secondary to the weight of the breasts being transferred to the 
shoulder strap area, headache, and congenital breast deformity. In this case, the patient has a 
history of back and neck pain. The patient also presented with rheumatoid arthritis, spinal stenosis, 
degenerative disc disease, and herniated disc. There is a lack of documentation of chronic breast 
pain  due  to  weight  of  the  breasts,  thoracic  kyphosis,  shoulder  grooving,  upper  extremity 
paresthesia, headache, or congenital breast deformity. The patient complained of intertrigo, but 
there is a lack of documentation that the patients condition was unresponsive to adequate medical 
management. Overall, there are fewer than two documented quality-of-life signs as defined by the 
ASPS. Therefore, the breast reduction surgery performed on 9/12/22 was not medically necessary 
for the treatment of this patient.
Summary Reviewer 1

A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that there is a lack of support for the requested device in this patients case. The records do not document a nonsteroidal anti-inflammatory drug trial. There is no surgical consultation that addresses the extruded disc in her neck. While there is literature supporting the use of cervical spinal cord stimulator for cervical radiculopathy, there are several available alternatives before embarking on spinal cord stimulation. Therefore, the implanted electrical stimulator is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 2

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. This patient has been diagnosed with gastroesophageal reflux disease. On 1/07/19, while the patient was on lansoprazole, the provider suggested a trial of hypoallergenic formula. The provider also recommended gastroenterology evaluation. On 2/15/19, the records noted that that the patient was intolerant of the hypoallergenic formula. However, the records do not provide additional details regarding the symptoms of intolerance. Proton pump inhibitor therapy is recommended in infants only when there are findings of erosive esophagitis or in the presence of certain anatomic abnormalities (such as repaired tracheoesophageal fistula/esophageal atresia). Given that esophagitis was not documented in this case, lansoprazole is not likely to be more effective than other treatment options.
Summary Reviewer 3

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Lansoprazole may be indicated in select cases, such as patients with esophagitis and postoperative esophageal dysmotility. The article by Hassall and colleagues noted the presumed safety and efficacy of proton pump inhibitor therapy in this age-group, but this was in the setting of defined esophagitis. It is difficult to label an infant as having an acid-related disease based on clinical assessment alone. The trend has shifted away from routine use of prolonged acid suppression in otherwise healthy infants. There may be a role for empiric use in the setting of feeding aversions or poor weight gain, but neither of those situations were demonstrated here. Thus, lansoprazole is not likely to be superior over other treatment options.