Persius/imr-appeals huggingface dataset:
Summary Reviewer 

A 31-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine, cervical spine, and pelvis. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees back and neck pain. The physician reviewer found that the records provided for review do not support the medical necessity of the requested MRI studies. The physical examination on 5/16/18 does not detail which muscles are weak or hypotonic. In addition, the neurological examination was limited and the note of prior physical therapy does not include details as to duration, evaluation or outcome. Moreover, there are no laboratory values in the chart to support an indication for an inflammatory process such as sacroiliitis. All told, there is a lack of documentation supporting the medical necessity for MRI of the lumbar spine, cervical spine, and pelvis for evaluation of this patients medical condition. Based on the foregoing discussion, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that FoundationOne assay explores possible mutations in 324 genes, as well as certain other abnormalities, in an individualas cancer cells. At this time, there is a lack of convincing evidence that therapy that is determined by the assay is superior to that which an oncologist would recommend from the literature and experience. Finding a mutation does not guarantee that a treatment directed at that will be effective. It has been estimated that the percentage of patients who would benefit from using the assay to select therapy is quite small. The National Comprehensive Cancer Network guidelines for treatment of ovarian cancer does not recommend using such an assay in the selection of therapy. Therefore, laboratory services provided on 8/15/19 were not likely to have been more beneficial than other available standard therapy.
Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that contrast-enhanced breast MRI is more sensitive for the detection of breast cancer in the high risk population than both mammography and ultrasound. Screening breast MRI is recommended in women with BRCA gene mutations, their untested first-degree relatives, and women with a lifetime risk of greater than 20%. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. A common screening protocol is alternating MRI with mammography/ultrasound every six months. This patient has a known BRCA1 gene mutation and is therefore considered one of the highest risk populations for breast cancer. She is alternating mammography/ultrasound with MRI every six months. Due to pregnancy and subsequent breastfeeding, she was unable to obtain her annual screening MRI, which would have been due February 2017. Therefore, MRI was appropriately performed in January 2018 after the cessation of breastfeeding, according to her screening schedule. Thus, bilateral breast MRI performed on 1/28/18 was likely to have been of more efficacious than other modalities for evaluating this patient. 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  
The patient is  a  27-year-old male who was  admitted  for  hospitalization  on  8/13/21  after 
presenting  with  progressively  worsening  abdominal  pain  with  vomiting.  The  patient  has 
requested reimbursement for inpatient admission (hospital treatment services) from 8/13/21 
through 8/15/21. The physician reviewer found that at issue is whether inpatient admission 
(hospital treatment services) from 8/13/21 through 8/15/21 was medically necessary for the 
treatment of this patient. The submitted documentation does not support the medical necessity 
of the services at issue. Inpatient care may be necessary when a patients signs, symptoms, and 
general medical condition can only be managed safely in an acute inpatient setting, when a 
patient requires diagnostic studies in an inpatient setting, or when it is necessary for the patient 
to remain in an acute inpatient setting. In this case, the patient was hemodynamically stable and 
afebrile at admission. After treatment in the emergency department, the patients symptoms of 
pain and vomiting improved. The records did not indicate that the patient required any urgent 
procedures or surgical intervention. He did not have any significant electrolyte disturbances. He 
was treated with a nasogastric tube for a short time but able to tolerate oral nutrition shortly 
after  admission.  His  symptoms  improved  quickly  with  treatment  and  he  did  not  have 
complications. Given that this patient was in stable condition at admission and could have been 
treated at a lower level of care, the services at issue were not medically indicated. Therefore, 
inpatient  admission  (hospital  treatment  services)  from  8/13/21  through  8/15/21  was  not 
medically necessary for the treatment of this patient.
Summary Reviewer 2


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found the most important considerations in the use of bronchial thermoplasty are the proper selection of patients and ensuring an experienced qualified provider is performing the procedure. Bronchial thermoplasty has adequate data on long-term safety and effectiveness in patients with asthma in terms of demonstrating improvement in symptoms and reduction in exacerbations. On the basis of daily symptoms, frequent rescue medication use, interference with daily activities and frequent exacerbations, this patient meets criteria for severe persistent asthma. However, there is not adequate information provided to determine two important considerations in the treatment of asthma. First, the records do not document that alternate diagnoses have been ruled out. The appearance of infiltrates and adenopathy on the computed tomography (CT) may indicate a secondary cause of wheezing. Secondly, there was not information provided to exclude other asthma therapies such as omalizumab or mepolizumab based on IgE levels or eosinophil counts. All told, there is a lack of documentation supporting the requested bronchial thermoplasty as 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 requested procedure 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 

A 62-year-old male enrollee has requested reimbursement for long term acute care provided from 10/30/18 through 1/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support. Long-term acute care hospitals offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day. The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care (e.g., ventilator-dependent). The long-term acute care hospital setting is considered when the patients need for nursing and rehabilitative services are such that only an inpatient long-term acute care hospital setting can meet the requirements, and the expected length of stay is greater than 25 days. In this case, the documentation does not support that the patient required complex medical treatment (e.g., multiple and prolonged intravenous therapies; monitoring of significantly medically active conditions requiring clinical assessment six or more times a day; multiple and frequent intervention of at least six or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above; and the need for specialized high-tech equipment like cardiac monitors, on-site dialysis, or surgical suites) as of 10/30/18. The patient did not require services at the long-term acute care hospital setting that were not available at the acute care hospital or the skilled nursing facility. The requested treatments were not medically necessary at the long-term acute care hospital level of care from 10/30/18 through 1/10/19. Although the patient required hemodialysis, nutrition via a feeding tube and continued wound care, he was medically stable as of 10/30/18 and could have received services at a lower level of care. Therefore, long-term acute care provided from 10/30/18 through 1/11/19 was not medically necessary for the treatment of this patient.
Summary  
The patient is a 45-year-old female with a history of atopic dermatitis. The patient states that she 
stopped treatment with Dupixent after experiencing a disruption in treatment from September to 
November 2022. The patient has requested continued treatment with Dupixent. The Health Insurer 
has denied the requested treatment 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 U.S. Food and Drug Administration (FDA) has approved Dupixent for the 
treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately 
controlled with topical therapies. A recent consensus article on atopic dermatitis by Boguniewicz 
and colleagues defined moderate-to-severe atopic dermatitis as more than 10% BSA involvement 
and/or involvement of highly visible areas or those important for function and significantly 
impaired quality of life. On review of the current medical literature, Dupixent has the highest-
quality clinical trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). The 
records provided for review document that the patient has severe atopic dermatitis and atopic 
neurodermatitis, with 20% BSA involvement. The provider noted that the patient has tried and 
failed treatment with topical steroids, antibiotics, and tacrolimus. The patient has previously 
undergone treatment with Dupixent with significant relief of symptoms. Given these findings, the 
requested Dupixent 300 mg/2 mL, four pens per 28 days is medically necessary for the treatment 
of this patient.
Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for breast susceptibility gene (BRCA) testing.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found BRCA mutations are associated with a high incidence of both breast and ovarian cancer. Being BRCA positive has several implications for measures to be considered by the patient.  With regards to breast cancer, she can consider more intense screening with magnetic resonance imaging or even bilateral mastectomies.  With regards to ovarian cancer, it is recommended that such women have bilateral salpingo-oophorectomy at the appropriate age.  Thus BRCA is a genetic test of great potential importance and value.  However, there is a lack of support for the requested services in this patients case.  U.S. Preventative Services Task Force indicates that testing is recommended for women who have a family history including three or more first-degree or second-degree relatives with breast cancer, regardless of age of their diagnosis.  Additionally, there is support for BRCA testing for patients who have a close relative diagnosed with breast cancer under the age of 50.  None of these criteria appear to apply to this patient.  All told, the requested breast susceptibility gene (BRCA) testing is not medically indicated for the evaluation of this patient.  Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found that currently, there is a paucity of proven significant health or functional benefits of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry for use in this clinical setting. There have been a number of case reports and series providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury are lacking. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially retard or reverse muscle atrophy in paralyzed muscle, there is no proven significant health or functional benefit of this achievement in patients with spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide any other clinically or functionally relevant benefit. Passive cycling may be an option to provide passive range of motion therapy to prevent contractures or mitigate spasticity, but this is considered a custodial use of the device (Reichenfelser, et al). The other purported benefits of passive cycling have not been sufficiently investigated to allow conclusions related to clinically relevant outcomes. To date, the limited available data provide mixed results regarding health measures. Given that the RT300 FES cycle is not active exercise and not an appropriate substitute for active exercise, its use in this patients care was not indicated. Thus, the RT300 FES cycle provided on 2/10/16 was not 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 equipment at issue was 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 3


A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found the RT300 FES is a primary at-home internet linked and remote-clinician monitored intervention for patients with spinal cord injury (SCI) that provides intense electrical stimulation to intact peripheral nerves below the level of the SCI to evoke muscle contractions. Physical activities, like FES, that provide adequate stress to bone, can play a role in the improvement in bone mineral density with the possible prevention or reduction of osteoporosis and a decrease in fractures, two disabling and costly conditions for persons with paralysis due to SCI (Dolbow, et al). In addition, Fazio noted that repeated use of FES can lead to sensorimotor improvements as well as cortical reorganization, changes that cannot be accomplished with passive range of motion alone due to lack of sensory or motor input or activation of motor units, which is essential for motor relearning and neuromuscular reeducation. Thus, the intended in-home use of the RT300 FES cycle will help to remove many of the physical barriers to exercise which is a key factor in promoting regular physical activity in the SCI patient. For these reasons, the RT300 FES cycle provided on 2/10/16 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 equipment at issue was 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 3

A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breasts have been described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on 3/22/16 was likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the service at issue was 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 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based upon the recommendations of the National Oncologic PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its guidelines concerning coverage for PET scans in patients with solid tumors allowing up to three scans in each patient for diagnosis, staging and surveillance. While the use of this compound has proven to be of use in prostate cancer, the re-approval of 18F-NaF as a pharmaceutical has proven of greater benefit to patients with rising PSA levels where bone metastases are possible. The reason is the proven marked increased sensitivity of the technique compared to standard technetium bone scans in the detection and localization of skeletal metastatic deposits. In this patient with a rising PSA after radical prostatectomy, the possibility of subtle skeletal metastatic disease is possible and the requested 18F-NaF PET/CT scan is the most sensitive means with which to evaluate this patient.  Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 3

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. 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, 0.76-1.0 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 the DecisionDx-Melanoma testing for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also 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, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been more effective 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 2 
 
A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from 
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The 
physician reviewer found that therapeutic phlebotomy is the preferred approach to removing 
iron in patients with hereditary hemochromatosis because it is highly effective and relatively 
devoid of toxicities. In this case, phlebotomy was indicated as the records noted a biopsy proven 
iron overload. While there is a range of ferritin and iron saturation goals, the recommended 
ferritin goal is 30 to 150 ng/mL and the recommended iron saturation goal is greater than 20%. 
In this case, laboratory results dated 12/14/20 showed a ferritin of 369 ng/mL and an iron 
saturation over 85%. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely 
to have been more beneficial for treatment of the enrollee's condition than any available 
standard therapy.
Summary Reviewer 

A 58-year-old male enrollee has requested authorization and coverage for epidural steroid injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patients physical examination and lumbar magnetic resonance imaging (MRI) do not show evidence of lumbar radiculopathy/radiculitis.  The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis.  The patients chronic pain condition is not consistent with such a diagnosis.  There is a lack of support for the requested services in this clinical setting.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.