Persius/imr-appeals huggingface dataset:
Summary Reviewer 


A 31-year-old female enrollee has requested reimbursement for inpatient mental health services provided from 11/7/17 to 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder and depression. The physician reviewer found that applying the level of care utilization system (LOCUS) criteria, the inpatient mental health services provided from 11/7/17 to 12/6/17 were not medically necessary for treatment of this patients behavioral health issues. The patient presented with significant risk of harm (score 3) with a history of a suicide attempt at age 15 by attempting to overdose on Advil. The patient also has a history of self-cutting from the ages of 14-19 years old. On 11/7/17 and several days prior, the patient had intermittent passive suicidal thoughts. The patient demonstrated moderate functional impairment (score 3) and due to her symptoms, the patient was unable to fulfill her responsibilities in her work. The patient showed significant co-morbidity (score 3) with history of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors. The patient did not have substance abuse problems. The patients recovery environment is mildly stressful (score 2) as she demonstrated distress while she was traveling in Paris due to isolation. The patients recovery environment was supportive (score 2) and she demonstrated moderate response to prior treatment (score 3). The patient demonstrated positive engagement and recovery (score 2) as she was described as attentive and engaged during treatment. The patient had a positive attitude toward recovery and treatment. These findings give the patient a composite score of 18, which is consistent with intensive outpatient program (IOP) level of care. The patient continued to require treatment for her of bipolar II, cluster B traits, and bingeing, purging, and restricting behaviors, but this could have been safely and effectively provided in a less restrictive environment. Therefore, the services at issue were not medically necessary. 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 

The patient is a 28-year-old transgender female who is seeking facial feminization surgery.  The Health Insurer has denied coverage for facial feminization surgery. Per the Health Insurer, the requested services are 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 purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. World Professional Association for Transgender Health, Inc. (WPATH) states, Non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. WPATH notes, These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. The current medical evidence supports the requested services in this patients case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Summary Reviewer 


A 29-year-old female enrollee has requested reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward. The Health Insurer has denied this request indicating that the medication dosage at issue was not and is not medically necessary for treatment of the enrollee who has been assessed with chronic pain syndrome. The physician reviewer found that the medical literature states that dose escalation is not a long-term plan but a short-term plan for the treatment of tolerance. In the documentation available for review, there were no objective treatment goals for pain and function noted for the requested medication. In addition, several requirements for opioid prescribing have not been documented to be performed. Therefore, the need to use them as the primary medication treatment strategy for pain has not been established (Chou, et al). The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, providers should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day or carefully justify a decision to titrate dosage to 90 or more MME per day. In this case, the patient was recently taking 135 MME per day. However, there is no submitted evidence based rationale given by the provider to support the potential long-term consequences with the continual increase in opioids. Risk and benefit analysis must be performed to justify the requested level of 90 MME per day. It is also reasonable to consider alternatives to opioids. Moreover, pure mu agonists are not considered evidence based treatments for fibromyalgia and the adverse effects of opioids in fibromyalgia patients are unknown. In addition, the submitted records do not mention the completion of behavior therapy despite much research to support its use. For all of these reasons, reimbursement and prospective authorization and coverage for OxyContin 20 mg three times per day from 2/9/18 forward has not been demonstrated as medically necessary for treatment of the patients medical condition. Therefore, based on the reasons stated above, the medication dosage at issue was not and is not medically necessary for the treatment of this patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 

The patient is a 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. The randomized PURSUIT study showed that Simponi serum concentrations are proportional to dose, and higher Simponi concentration was associated with improved clinical outcomes. Studies have shown that dose escalation can recover response to therapy in a significant fraction of patients. One study showed recovery of response in 71% of ulcerative colitis patients undergoing Simponi dose escalation, and another demonstrated improvement in half of patients (Taxonera and Rodriguez, et al; Taxonera and Iborra, et al). In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin. Dose escalation can recover response and prevent complications, such as disease flare, hospitalization, toxic megacolon, and dysplasia with risk of colorectal cancer. Therefore, Simponi 100 mg every 21 days is medically necessary for the treatment of this patient.
Summary Reviewer 


A 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the medical records provided for review do not support the medical necessity of the RTC services provided from 6/11/17 through 7/2/17 for treatment of this patients behavioral health issues. On 5/27/17 admission, the patients symptoms prevented him from functioning properly. However, by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg. Further, Clozaril titration does not require a RTC setting and can be performed in the outpatient setting. His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment. He no longer required 24-hour monitoring in the RTC setting, and could have continued treatment at IOP level of care. Thus, the RTC services provided from 6/11/17 through 7/2/17 were not medically necessary. 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 1

A 66-year-old female enrollee has requested authorization and coverage for 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 enrolleeas obstructive sleep apnea. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure therapy, anterior posterior collapse, no central apnea, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.
Summary Reviewer 2

A 66-year-old female enrollee has requested authorization and coverage for 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 enrolleeas obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this patientas case. She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. The alternative, no treatment, may lead to potential harms, such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale scores.  The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.
Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). 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 fails to demonstrate the superior efficacy of the requested services. The U.S. Food and Drug Administration has approved the LINX device for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug. As such, he cannot be considered refractory to medical management. Given this patients excellent response and tolerance to conventional acid suppression medication and the attendant surgical risks of LINX implantation, the requested CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.
Summary Reviewer 1


A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. 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 the submitted letters from the patient and provider were reviewed.  However, there is a lack of additional pertinent medical documentations, such as progress notes from the ordering provider.  The progress notes submitted are from a different provider which documented the diagnosis of mast cell disorder, chemical sensitivities and food allergy.  The only records from the ordering provider were testing records, which are insufficient to support the services at issue.  The submitted records do not support a covered indication for the services at issue.  Based upon the information set forth above, the services at issue were 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 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Allergen immunotherapy is a long-term treatment that decreases symptoms for many people with allergic rhinitis, allergic asthma, conjunctivitis or stinging insect allergy.  Allergy shots decrease sensitivity to allergens and often lead to lasting relief of allergy symptoms even after treatment is stopped.  Indications for allergen immunotherapy include allergic asthma and rhinitis, conjunctivitis, as well as venom-induced anaphylaxis.  In this patients case, the records do not support the services at issue.  Without a diagnosis of asthma, rhinitis, conjunctivitis or anaphylaxis, the services at issue cannot be recommended.  In sum, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 were not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were 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

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 this patient had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. The role of DecisionDx-Melanoma testing for recurrent node positive disease has not been established. In sum, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Summary Reviewer 2

A 29-year-old female enrollee has requested reimbursement for the Anser ADA test provided on 10/13/14. 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 that antibodies to adalimumab (ADA) are present in a substantial number of patients treated with adalimumab, and in some patients there may be a correlation between the level of these antibodies and clinical response. However, there are technical factors relating to the use of different assay methods across studies, and it has not yet been established whether the use of threshold level aid in the discrimination of response to adalimumab. There are patients who do not respond to adalimumab (primary non responders), and patients who appear to lose their response to adalimumab over a period of time (secondary non responders). However, some evidence suggests that low serum drug levels and/or the presence of drug antibodies to may play a role in primary or secondary response failures. Menting and colleagues noted that patients with no ADA formation in the first 24 weeks of treatment have little chance of it in the following 24 weeks. The presence of ADA is strongly correlated with adalimumab concentration. Standard alternatives to Anser ADA testing, in patients like this patient, include shortening the interval between doses, increasing the dose, or switching to a different agent. At this time, the peer-reviewed medical literature does not support the use of the Anser ADA test as performed on 10/13/14 as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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 female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Turner and colleagues reported that treatment with Ibrance and Faslodex is approved for ER positive metastatic disease. The authors reported that among patients with hormone receptor positive metastatic breast cancer who had progression of disease during prior endocrine therapy, Ibrance combined with Faslodex resulted in longer progression-free survival than Faslodex alone. Given this support, the requested Ibrance 100 mg is supported 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 medication is 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 five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay. The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the request for genetic testing is medically necessary for evaluation of the patients medical condition. The clinical utility of CMA is well established in the peer-reviewed literature and is considered a first-line genetic test for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). CMA technology has been shown to provide clinically actionable information. The study by Coulter and colleagues demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, and specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Current data suggest that many clinically significant genetic changes can impact neurodevelopment without associated anatomic departures. For the reasons provided, the request for genetic testing has been established as medically necessary for evaluation of the patients medical condition. Therefore, the requested testing is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for disc fusion. 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 the submitted documentation supports the medical necessity of the services at issue. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. With regard to the type of interbody spacer used, frozen allograft is associated with lower pseudarthrosis rates compared with freeze-dried allograft. Based on these guidelines, the requested anterior lumbar interbody fusion procedure is likely to be beneficial for this patients severely symptomatic degenerative disc disease with a 4 mm protrusion at L5-S1 that did not respond to nonoperative treatment. Therefore, the requested 63077, 22558 and 22845 are medically necessary for the treatment of this patient.