Persius/imr-appeals huggingface dataset:
Summary Reviewer 

A 48-year-old female enrollee has requested authorization and coverage for Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that dermatomyositis is an idiopathic inflammatory myopathy. In this case, the patient has been diagnosed with dermatomyositis. Her treatment has included prednisone alone. Initial therapy for individuals diagnosed with this disorder includes high-dose glucocorticoid therapy with a taper to the lowest effective dose. Generally, a glucocorticoid-sparing agent is used in combination with glucocorticoid therapy. Treatment includes prednisone in combination with methotrexate, azathioprine or CellCept. In this case, the patient has only been treated with prednisone, and the requested medication is not considered a first-line medication. There is no documentation that she has failed treatment with a glucocorticoid-sparing agent, such as methotrexate, azathioprine or CellCept, which are considered first-line medications. The requested medication, Gamunex-C is not medically indicated. Therefore, Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml) is not medically necessary for the treatment of this patient.
Summary  
The patient is a 52-year-old female with a history of refractory back pain, depression, anxiety, 
and chronic pain disorder status post pain pump placed in 2019. The provider has recommended 
placement of a percutaneous implantation of spinal cord stimulator. The physician reviewer 
found that at issue is whether the requested percutaneous implantation of neurostimulator 
electrode array, epidural, is medically necessary for treatment of this patient. A prospective, 
multicenter, randomized controlled trial was conducted evaluating the long-term quality of life 
improvement for patients with chronic intractable back and leg pain using spinal cord stimulation 
(Amirdelfan, et al.). The authors reported that of the 171 patients who received a permanent 
spinal cord stimulation device implant, a higher proportion of spinal cord stimulation patients 
had marked improvement of their disability on the Oswestry Disability Index (ODI) to a moderate 
or minimal impact on their daily function versus the control group. The authors concluded that, 
In  addition  to  superior  pain  relief,  10  kHz  spinal  cord  stimulation  provides  long-term 
improvements in quality of life and functionality for subjects with chronic low-back and leg pain. 
Similarly, a systematic review and meta-analysis performed by Head and colleagues evaluated a 
variety of spinal cord stimulation systems and device parameters for use in patients with chronic 
low back and leg pain. The authors concluded that data from level 1 randomized controlled trials 
have elevated the status of spinal cord stimulation to a safe and effective alternative for the 
treatment of neuropathic low back pain and leg pain. In this case, the patient has chronic low 
back pain that has been non-responsive to medication management, physical therapy, epidural 
steroid injections, cognitive therapy and intrathecal pain pump. Based on the level one evidence 
to support the usage of spinal cord stimulation therapy for patients with chronic low back and 
leg pain that is refractory to other forms of conservative care, the requested spinal cord 
stimulation is appropriate for treatment of this patients chronic low back pain. Therefore, the 
requested percutaneous implantation of neurostimulator electrode array, epidural, is medically 
necessary for treatment of this patient.
Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. 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 sufficient support for the requested services in this clinical setting. The records noted intolerance to the use of continuous positive airway pressure therapy. A sleep study documented symptoms of obstructive sleep apnea with an apnea-hypopnea index at the moderate to severe level of obstructive sleep apnea syndrome, with oxygen desaturation to 82%. Hypoglossal nerve stimulation therapy has been demonstrated to be an effective modality for the treatment of obstructive sleep apnea in patients with tongue-based obstruction. The medical evidence supports the requested services for the treatment of this patient. Thus, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be of greater benefit than other treatment options.
Summary Reviewer 1

A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 Osteoporosis is a condition of thinning of the bones that leads to an increased risk of fracture.  It  is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults), as measured by dual-energy x-ray absorptiometry (DEXA). Bone mineral density assessment via DEXA is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 


The parent of a 15-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 5/9/15 through 8/7/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and parent-child relational problem.  

 The physician reviewer found that the documentation provided for review does not support the medical necessity of residential mental health treatment services provided from 5/9/15 through 8/7/15. There is no evidence that treatment in a less restrictive setting would have been ineffective to manage the patient, since this had not been given an adequate trial. Similarly, there is a lack of objective evidence that continuation with a lesser intensity of care could not have provided improvement or prevention of deterioration. The patients level of symptomatology did not justify residential services. No suicidal ideations or homicidal ideations had been documented, but in one incident, which was assessed as an attempt to manipulate the staff. The patient was able to contract for safety and no additional intervention occurred. Further, continued residential services, especially at the highly intensive levels that were used, may have led to service dependency, which would be an adverse outcome. Therefore, this patient would have been more appropriately managed at a less restrictive, less intrusive intensity of services, such as outpatient care. For these reasons, the residential mental health treatment services provided from 5/9/15 through 8/7/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that this patient presented on 6/15/18 with recurrent right knee pain and limitations in functional mobility and activities of daily living. Clinical examination findings were consistent with reported radiographic evidence of right knee degenerative joint disease. Reasonable conservative treatment, including medications, activity modification, weight loss, and physical therapy have failed to provide adequate symptom relief. She was status post previous injections on 12/19/16 and 9/22/17 which had provided sustained pain relief and functional improvement for longer than six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, knee injections provided on 6/15/18 were medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 2


A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Chromosomal microarray testing is an appropriate first-line test for patients with non-syndromic developmental delay/intellectual disability, as well as patients with autism spectrum disorders.  There are clear management implications that chromosomal microarray testing has provided for patients.  In sum, FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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

The patient is a 25-year-old female with a history of chronic sinus problems. The provider reports the patient presented with symptoms of recurring sinus infections requiring antimicrobial treatment four times in the preceding four months. The patients symptoms included facial pressure, headache, generalized fatigue and nasal congestion. The physical examination documented clear mucus and nasal septal deviation suggestive of acute rhinitis, most likely to be of bacterial origin and the provider recommended use of a topical fluticasone nasal spray and nasal irrigations along with computed tomography (CT) imaging of the paranasal sinuses. On 2/13/18, a follow-up note documented that the patient had been evaluated for nasal airway obstruction due to deviated nasal septum and rhinorrhea. CT imaging on 12/27/16 demonstrated that the frontal, ethmoid, maxillary and sphenoid sinuses were clear and that the sphenoid and frontal sinuses were found to be hypoplastic. The ostiomeatal units were found to be patent. This was in comparison to the previous CT scan dated 8/18/16. The patient has requested reimbursement for the CT maxillofacial without contrast material provided on 12/27/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary. Upon the review of the documentation, the provider stated in the physical examination that the patient did have symptoms of recurrent acute sinusitis over four months or longer and had been placed on multiple different medical therapies including antibiotics and other medications, but still had repeated rhinosinusitis. The patient was found on physical examination to have persistent rhinorrhea in addition to nasal septal deviation, which is one of the physical findings on examination to meet criteria for CT scan imaging. Practice guidelines acknowledge that CT imaging, as opposed to the plain radiography or magnetic resonance imaging (MRI), is the diagnostic modality of choice for confirming chronic rhinosinusitis or as an alternative to nasal endoscopy. Thus, the CT maxillofacial without contrast material provided on 12/27/16 was medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 1


A 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that some evidence exists to suggest that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. However, the reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, the Anser IFX testing provided on 10/26/15 was 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 testing at issue was 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 3

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. 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 the submitted documentation supports the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulator has been demonstrated to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. This procedure has been approved by the U.S. Food and Drug Administration. With a body mass index of 26.6, apnea-hypopnea index of 19.3 and nonconcentric airway collapse, this patient meets the criteria. He has failed continuous positive airway pressure therapy, which is the gold standard treatment for obstructive sleep apnea. Thus, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be of greater benefit than other treatment options.
Summary Reviewer 

A 46-year-old male enrollee has requested authorization and coverage for an oral appliance. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees mild obstructive sleep apnea. The physician reviewer found that the submitted documentation supports the medical necessity of the requested device. The patient has been diagnosed with mild obstructive sleep apnea. Per the records, treatment with CPAP was initially recommended. The clinical notes indicate that the patient is unable to tolerate CPAP therapy. For patients who are unable to tolerate CPAP therapy, treatment with an oral appliance has been shown to improve symptoms of obstructive sleep apnea. The medical evidence supports the requested device in this clinical setting. Thus, the requested oral appliance is medically necessary for the treatment of this patient. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 2

A 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. 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 that this patient had an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures.  There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing performed on 12/11/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer  
 
The patient is a 61-year-old male who was admitted for hospitalization on 8/5/21. The patient 
has requested reimbursement for inpatient hospital level of care from 8/5/21 through 8/7/21. 
The Health Insurer has denied this request and reported that the services at issue were not 
medically necessary for the treatment of this patient. The physician reviewer found that the 
submitted documentation supports the medical necessity of the services at issue. In this case, 
the patient presented with non-ST-elevation myocardial infarction (NSTEMI), a form of heart 
attack, and pulmonary edema in the setting of rapid atrial fibrillation requiring rate control by 
continuous intravenous diltiazem infusion. At the time of presentation on 8/5/21, the patient 
was at risk due to persisting rapid atrial fibrillation, worsening/evolving heart failure, respiratory 
failure,  and  sudden  cardiac  death.  Given  this  adverse  risk  profile,  the  patient  warranted 
admission to inpatient status to facilitate intravenous diuresis or volume removal, close cardiac 
monitoring with telemetry and repeat biomarkers, and continued intravenous infusion for rate 
control to treat the underlying cause of his condition. Moreover, at the time of the inpatient 
order, it was reasonable to anticipate the patient would cross two midnights while receiving 
medically necessary care, often considered the benchmark for inpatient admission, which was 
the case for this hospital stay. In addition, the patient required ICU level care due to (1) his 
pulmonary edema and tenuous respiratory status, and (2) his need for continuous intravenous 
infusion of diltiazem, which cannot be safely delivered on the regular medicine floor in most 
hospital systems. Therefore, inpatient hospital level of care from 8/5/21 through 8/7/21 was 
medically necessary for the treatment of this patient.
Summary Reviewer 


The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. 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 autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. Based on the documentation submitted for review, the patient presents with symptoms consistent with autism. Maladaptive behaviors including aggression and tantrums are difficult to treat with other interventions. The research shows that although medications including Risperdal can reduce some of the aggression in children with ASD it does not treat the core symptoms and does not provide long term benefits. Matson and Jang performed a literature review on treating aggression in persons with ASD and found that the most effective interventions were behavioral interventions including ABA therapy. Based on the support in the peer-reviewed literature and the documented regression in behaviors with a reduction of hours, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.