Persius/imr-appeals huggingface dataset:
Summary Reviewer 

The patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a.
stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
In terms of risk of harm, the records support a score of 3. He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.
With regard to functional status, the records support a score of 3. The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.
In terms of comorbidity, the records support a score of 3. He has insulin dependent diabetes mellitus. There was nothing in the notes to indicate that his blood sugars were unstable.
With regard to level of stress of the recovery environment, the records support a score of 3. He was unable to work due to COVID-19 restrictions and was financially dependent on his mother.
In terms of level of support of the recovery environment, the records support a score of 2. The patientas mother participated in treatment.
With regard to resiliency and treatment history, the records support a score of 3. The patient has had emotional problems since childhood and has struggled with substance use.
In terms of engagement and recovery status, the records support a score of 2. He had acceptance of his illness and was engaged in his treatment. He was motivated to get better.
Thus, the records support a composite score of 19. Intensive outpatient program level of care was medically indicated. Therefore, intensive outpatient program services provided from 7/15/20 through 10/08/20 were medically necessary for the treatment of this patient.
Summary Reviewer 3

A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. 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 patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patients symptoms and findings. This patient reported itching and discharge. The services performed in this patients case were clinically appropriate. Per the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin number 215, Although microscopy with Amsel criteria and Gram staining with Nugent scoring remain the preferred methods and the most cost-effective way to diagnosis bacterial vaginosis, some newer commercially available diagnostic tests show promise for use in the clinical setting and may be considered when microscopy is unavailable. Per the medical evidence, this single-swab multiplex test may be a promising alternative to microscopy. Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 1
A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that there is support in the literature for the efficacy of the requested services in this clinical setting. Based on the overall documentation provided for review, the patient has failed standard therapy for correction of her complex abdominal hernia.  She has failed primary repair with synthetic mesh, as the mesh had become infected and had to be removed. This patient has evidence of a symptomatic, recurrent, left lower abdominal hernia.  She has a history of severe trauma and multiple reconstructive procedures of her abdomen.  She has noted to have failed previous mesh placement, as it had become infected and had to be removed.  Currently, she is symptomatic from her hernia with chronic pain, treated with an abdominal binder and chronic opioid use.  The requested Strattice (porcine biologic mesh) is used to reinforce the abdominal reconstruction provided by autologous tissue.  Strattice is a bioprosthetic porcine mesh. The medical literature indicates that bioprosthetic materials are preferred over synthetic materials for use in contaminated fields and should be strongly considered when the defect has bacterial contamination.  Patel and colleagues noted, Strattice is an effective adjunct to AWR (abdominal wall reconstruction) when used as reinforcement during CS (component separation) for a wide variety of indications. Complication rates remain low in complex patients. In addition, Strattice appears to add durability to midline reconstructions with no recurrences during the follow-up period.  In summary, this patient has exhausted standard therapy and Strattice has been shown to provide benefit in abdominal wall reconstruction. As such, implantation of Strattice is likely to be superior to the standard options available for treatment of this patients medical condition.Therefore for the reasons stated above, the requested services are 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 1


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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 3


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that 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 patients case, 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.  In sum, digital breast tomosynthesis performed on 8/01/16 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 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 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that intractable lower urinary tract symptoms and painful bladder/urethral syndrome related to interstitial cystitis can be clinically difficult to treat. Treatment options often are limited and have variable results. Patients often receive multimodal treatment, including proceeding to secondary and tertiary treatment options. Percutaneous tibial nerve stimulation is considered as a tertiary treatment option for intractable lower urinary tract symptoms and painful bladder syndrome with urgency frequency syndrome. There is some support for the requested services in this clinical setting. Therefore, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was likely to have been of greater benefit than other treatment options. 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 1 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low  back  pain.  The  physician  reviewer  found  that  according  to  the  U.S.  Food  and  Drug 
Administration (FDA), intraosseous nerve ablation is intended to be used in conjunction with 
radiofrequency for the ablation of basivertebral nerves for the relief of chronic low back pain of 
at least six months duration that has not responded to at least six months of conservative care 
and is also accompanied by features such as disruption and fissuring of the endplate. This 
patients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5 that would 
make the patient a good candidate for ablation of basivertebral nerves. However, the patients 
MRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral 
recess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion 
and mild central canal stenosis. Thus, there are multiple plausible pathologic sources of low back 
pain and finding the source of chronic lower back pain is clinically challenging (Tieppo Francio 
and Sayed). A small minority low back pain diagnoses can be attributed to an anatomical source. 
Overall, the medical evidence is insufficient to support a finding of spinal vertebral bodies as 
being the overwhelming primary generators of the patients chronic low back pain. Therefore, 
the requested intraosseous basivertebral nerve ablation (CPT code 64628) is not likely to be more 
beneficial than any other available standard treatments for the patients medical condition.
Summary Reviewer 3 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low back pain. The physician reviewer found that basivertebral nerve ablation is a minimally 
invasive outpatient procedure allowing for a quick recovery. The procedure is implant-free and 
preserves  spinal  integrity  by  negating  need  for  extensive  tissue  exposure  and  disruption. 
Additionally, basivertebral nerve ablation fills a treatment gap for patients with chronic low back 
pain and preserves future treatment options. In one study, patients with chronic low back pain 
who underwent basivertebral nerve ablation reported significant improvement in pain and 
function with well documented long-term effectiveness and durability (Fischgrund, et al.). This 
patient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results 
demonstrated changes at disc space endplates L4-5. This patient has undergone more than six 
months of conservative treatment consisting of intradiscal steroid injection, home exercise and 
physical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient 
and  durable  relief.  This  patient  does  not  warrant  more  invasive  treatment,  such  as 
decompression and fusions, as there are no reported severe symptoms of lumbar radiculopathy. 
Given these findings the requested intraosseous basivertebral nerve ablation (CPT code 64628) 
is likely to be more beneficial than any other available standard treatments for the patients 
medical condition.
Summary Reviewer 

The patient is a 56-year-old transgender female who has been diagnosed with gender dysphoria. The patient has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health position statement states, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a There is sufficient support for the requested services in this patientas case. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Summary Reviewer 


The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).  The physician reviewer found the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness. The medical literature supports hospitalization for observation for cardiopulmonary monitoring for 23 hours after an ALTE in the majority of infants (Fu and Moon; McGovern and Smith). However, certain individuals can be discharged from the emergency department without hospitalization (Kahn and European Society for the Study and Prevention of Infant Death). Given that the patient was well-appearing at the time of presentation, had no further events during observation in the hospital, did not require specific interventions or extensive evaluation beyond observation, and was discharged home on the same day of admission, he met criteria for observation but not admission. Based upon the information provided and reviewed and the medical literature reviewed, the inpatient hospital level of care provided on 3/31/16 was not medically necessary for treatment of the patients medical condition. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 3

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the 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 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 8/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Summary Reviewer 3 
A 28-year-old female insured has requested authorization and coverage for intravenous (IV) 
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insured's refractory relapsing polychondritis. 
The physician reviewer found that there is limited medical literature studying IVIG as a treatment 
option for patients with relapsing polychondritis. Relapsing polychondritis is a rare autoimmune 
disorder, and official guidelines to utilize certain therapies are not likely to be available in the near 
future. However, for patients who have tried and failed treatment with multiple therapies from 
several classes of medications, IVIG is appropriate as the next-line treatment option. This is 
particularly applicable when its efficacy has been established for a particular patient in keeping 
the disease stable or in remission. According to one study by Lekpa and Chevalier, IVIG has been 
shown to be effective in some patients with relapsing polychondritis. In this case, the patient 
presents with relapsing polychondritis. The records provided for review indicate that the patient 
has tried and failed treatment with multiple therapies from several classes of medications. The 
provider has recommended a continuation of IVIG therapy which has already been shown to be 
the most effective treatment option for this patient. All told, the requested IV Gammagard is likely 
to be more beneficial for the treatment of the patients condition than any available standard 
therapy.
Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. 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 once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen (PSA) level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities, because many patients will not require therapy (i.e., surgery or radiation) and may be followed closely instead. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. The National Comprehensive Cancer Network guidelines also suggest the use of this test to better stratify such patients with localized disease. Thus, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Summary Reviewer 1

A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that there is a lack of medical literature supporting the service at issue in this clinical setting. Silverstein and colleagues studied intraoperative radiotherapy for early-stage breast cancer. The study revealed that intraoperative radiotherapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar. In addition, the American Society for Radiation Oncology (ASTRO) consensus guidelines recommended intraoperative radiation therapy for those with suitable criteria with invasive cancer, and not for patients with DCIS. Moreover, treatment with intraoperative radiation therapy is not the standard therapy for breast cancer. Given the lack of support in the peer-reviewed literature, the intraoperative radiation therapy performed on 7/19/16 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 service 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.