Persius/imr-appeals huggingface dataset:
Summary Reviewer 


A 55-year-old female enrollee has requested reimbursement for cervical spine surgery performed on 7/25/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees neck pain and tingling in the upper extremities.The physician reviewer found there is sufficient support for the services at issue in this clinical setting. Davis and colleagues performed a prospective, randomized, controlled, multicenter clinical trial on two-level symptomatic degenerative disc disease. Their findings supported the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two-level anterior cervical discectomy and fusion. The U.S. Food and Drug Administration has approved the use of artificial disc replacement for skeletally mature patients for reconstruction of the disc from C3-C7 following discectomy at two contiguous levels for intractable radiculopathy (arm pain and/or neurologic deficit) with or without neck pain, or myelopathy due to abnormality localized to the level of the disc space and at least one of the following conditions confirmed by radiographic imaging: herniated nucleus pulposus, spondylosis (defined by the presence of osteophytes) and/or visible loss of disc height compared with adjacent levels. This patient presented with persistent and worsening neck pain radiating down the left upper extremity, with tingling and weakness, and progressive right upper extremity symptoms. Associated symptoms included clumsiness and inability to grasp and hold objects. She was no longer able to work. Clinical examination findings evidenced C6 and C7 myotomal weakness consistent with imaging evidence of nerve root compromise at the C5-C6 level and bilateral neural foraminal stenosis at the C6-C7 level. Detailed evidence of long-term reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. Evidence-based criteria were met to establish the medical necessity of this surgical intervention. Therefore, the cervical spine surgery performed on 7/25/17 was 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 

The patient is a 51-year-old female who had a vaginal delivery in 2004 complicated by grade 4 episiotomy and Clostridium difficile on and off for six months. The patient has requested reimbursement for opium tincture 10 mg/mL provided on 2/18/20. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of this patient. The physician reviewer found that the use of opium tincture is supported as medically necessary for the treatment of this patientas incontinence and diarrhea. American Society of Colon and Rectal Surgeons guidelines for the treatment of fecal incontinence state that medical management should be first-line therapy, and opioids result in decreased intestinal motility, decreased intestinal secretion, and increased absorption. Opiates are recommended as safe and effective for the treatment of chronic diarrhea. The patient has been stabilized on opium tincture for several years. She has attempted several medical alternatives and has undergone sacral nerve stimulator. There is sufficient support for the requested medication in this setting. Therefore, opium tincture 10 mg/mL provided on 2/18/20 was medically necessary for the treatment of this patient.
Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for left and right eye refraction surgery performed on 9/19/16 and 10/07/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollee, who has a history of blurred vision. The physician reviewer found that the submitted submitted documentation supports the medical necessity of a portion of the services at issue. The records show that the patient did have symptomatic cataracts requiring surgery. The Health Insurers argument that the surgery was purely for refractive reasons was not substantiated upon reviewing the medical records. Thus, the portion of surgeries to treat cataract was medically necessary. The additional treatments of femtosecond laser and multifocal intraocular lens were for the purpose of refractive treatment and were not medically necessary. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 when performing thrombophilia screening, while the probability of a positive assay is higher in patients with a history of thrombus, the information provided does not help to inform future management. Various professional organizations have published guidelines indicating that routine thrombophilia screening in patients presenting with thrombosis should not be performed. In this
case, results of the thrombophilia screen is not likely to justify an evidence-based modification of this patients management. Furthermore, the consulting provider indicated that the deep vein thrombosis was considered to be a provoked event. The medical evidence does not support thrombophilia screening in this setting. In sum, laboratory testing performed on 6/26/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 3 
 
A 62-year-old male enrollee has requested authorization and coverage for proton beam therapy. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  service  is 
investigational for the treatment of the enrollees prostate cancer. The physician reviewer found 
that in this clinical setting, the only justified use for proton therapy would be in a clinical trial. 
Standard radiation therapy for prostate cancer is with x-ray IMRT radiation therapy, which has 
been shown to carry no long-term significant side effects. There is a lack of evidence in current 
medical literature showing improvement in terms of local control of the prostate cancer or for a 
survival benefit with the use of proton therapy. The NCCN guidelines note that photon or proton 
EBRT are both effective at achieving highly conformal radiotherapy with acceptable and similar 
biochemical control and long-term side effect profiles. Takeda and colleagues reported a very 
low  rate  of  grade  3  urine  toxicity,  which  is  not  life-threatening  and  does  not  require 
hospitalization, in patients with prostate cancer treated with IMRT and no in stances of grade 4 
toxicity. In a study regarding 15-year outcomes data for 301 patients with prostate cancer treated 
with x-ray IMRT, Weg and colleagues observed grade 3 gastrointestinal toxicity in three patients 
and no instances of grade 4 toxicity. The Radiation Therapy Oncology Group (RTOG) protocol 
notes that the small bowel can tolerate a maximum dose of 50 Gy, which is more than the typical 
dosage of 45 Gy in 2 gray equivalent dosage for EBRT treatment of elective lymph nodes for 
prostate cancer. In this case, the patient reported concern regarding the potential impact of ADT 
due to his history of hypogonadism. In this clinical setting, the NCCN recommends brachytherapy 
and EBRT, noting that ADT is only optional in this setting. Therefore, proton beam therapy is not 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Summary Reviewer 3

The patient is a 39-year-old female who underwent genetic testing during pregnancy.  Specifically, she underwent testing for the SMARCA4 gene mutation. The patient had a prior affected child with the SMARCA4 gene mutation leading to the child having Coffin-Siris syndrome. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. Per the records, there is a higher chance than the general population that the fetus may have the gene mutation SMARCA4 leading to Coffin-Siris syndrome.  Since this patient already had a severely affected offspring, the information from this testing was important in making important medical decisions regarding the pregnancy. Thus, SMARCA4 gene mutation and chromosome testing performed on 8/14/17 were likely to be of greater benefit 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 49-year-old male with a history of acute trauma to the thigh resulting in a thigh compartment syndrome. He underwent an emergency fasciotomy; however, the submitted documentation indicates the treating surgeon was not familiar with post-surgical care. The record noted a 14-inch draining skin incision. The patient was transported by air ambulance from Florida to Dallas, Texas. The patient has requested reimbursement for air ambulance services provided on 11/25/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary. This denial is the subject of this appeal and determination.  There is sufficient support in the documentation and the medical literature for the medical necessity of the services at issue. Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time are also crucial for optimization of functional and aesthetic outcomes. The patient had a 14-inch long draining wound and the submitted documentation indicates the initial surgeon was not familiar with current fasciotomy wound closure techniques. Transfer by air ambulance to a tertiary care institution was needed in light of the 14-inch long draining open wound and the patients pain. There was an urgent need for wound management at a tertiary care center to prevent deep infection, facilitate healing, and prevent complications such as deep vein thrombosis. The patient could not utilize public transportation due to the need for maximum assistance with ambulation. His ambulation was limited to use of bathroom only with assistance. He required dressing changes by medical personnel with sterile precautions as needed to keep wound clean during transport. While the record had noted that the patients vital signs were stable, stable vitals do not mean a sudden change in vitals cannot take place at any moment due to bleeding from an open wound. The presence of emergency medical personnel was essential. Tertiary care in Dallas, Texas was chosen because it was near his home. His treatment in Orlando, Florida would have necessitated a prolonged stay for follow-up care and inability to use public transportation. As noted above, the surgeon in Florida was unfamiliar with vacuum assisted closure.  Vacuum assisted closure technique has one of the lowest complication rates. In sum, air ambulance services provided on 11/25/17 were medically necessary for treating this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 

A 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states 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 trial. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, 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. Therefore, CPT 84999 performed on 10/17/18 was not medically necessary for the evaluation of this patient.
Summary Reviewer 1

The patient is a 64-year-old male with a diagnosis of hypogonadism. His symptoms include decreased energy and libido, mood swings, sleepiness and changes in fat/muscles. His pre-treatment testosterone level was 208 in 2011. The patient has been treated with testosterone injections and Testopel. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The use of Testopel is appropriate only for patients with an appropriate diagnosis of hypogonadism based on criteria recommended by national and international guidelines. Guidelines require measurement of two morning testosterone levels along with follicle-stimulating hormone/luteinizing hormone (FSH/LH) levels prior to initiation of therapy to identify the presence of and type of hypogonadism. In this case, the documentation submitted for review does not support that this was performed. In addition, patients who are on testosterone replacement should be monitored with laboratory work-up that includes testosterone, hematocrit, prostate-specific antigen (PSA), and lipid profile initially at frequent intervals and annually thereafter. Based on the clinical documentation submitted for review, the Testopel implants provided on 1/21/16 and 5/26/16 were 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 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 1


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  While autonomic testing can be useful in select cases where clear autonomic symptoms and findings have been documented, it should not be used in generic cases where a patient is noted to have pain.  In this case, the records do not clearly demonstrate marked autonomic findings or symptoms.  In the absence of this, autonomic testing has not been shown by clinical studies to statistically improve the management of patients.  The patient can be evaluated for treatable causes of peripheral neuropathies in the absence of the requested testing.  All told, autonomic nerve function testing performed on 3/26/15 was not likely to have been of greater benefit than other alternatives.  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 3


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the superior efficacy of the services at issue has not been established.  The patients history is not well-documented and does not indicate features of neuropathy.  The examination was inadequate to discern if neuropathy was a realistic consideration. Electrodiagnostic test results were not submitted for review.  If small fiber neuropathy is within the differential, commonly such individuals would be assessed by a neurologist familiar with neuropathy, and undergo more detailed neurologic clinical examination.  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 

A 51-year-old male enrollee has requested authorization and coverage for Octagam intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees bilateral upper extremity weakness and atrophy.  The physician reviewer found the records provided for review demonstrate that this patient developed progressive motor neuropathy that could be related to a variant of lower motor neuron syndrome. However, a variant of chronic inflammatory demyelinating polyneuropathy (CIDP), multifocal motor neuropathy or inflammatory neuropathy cannot be excluded. Considering the fact that the disease is active and progressive, a short trial of IVIG as recommended by the provider is appropriate. If the patient has an inflammatory neuropathy, he may respond to IVIG. In addition, the patients condition is active and he is losing axons. Delaying IVIG treatment in inflammatory neuropathy may limit the patients response to immunotherapy. An IVIG trial may help support or exclude the diagnosis of CIDP variant. Given this support, the requested Octagam IVIG is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 2

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that the submitted records fails to demonstrate the superior efficacy of the requested services in this clinical setting. In this circumstance, while there is increasing evidence to suggest that patent foramen ovale device closure may more effective than medical therapy alone for select patients age 60 years or younger with a cryptogenic non-lacunar ischemic stroke who have a patent foramen ovale, the patients most likely to benefit are those with large right-to-left interatrial shunting and/or an associated atrial septal aneurysm, neither of which is documented in this patient. Based on the documentation, medical management with aspirin is most appropriate in this case. In sum, heart surgery (93580, percutaneous transcatheter closure of heart defect) is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 3

The patient is a 64-year-old female who presented to the neurosurgery clinic after being diagnosed with a right carotid occlusion and high-grade stenosis of the left carotid artery.  She has a history of several transient ischemic attacks with complaints of dizziness as well as headaches and blurry vision. The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18.  The angiogram noted high-grade stenosis of the right vertebral artery is 70%, and a computed tomography (CT) perfusion revealed decreased blood flow to the right occipital lobe. During the postoperative examination, she continued with symptomatic dizziness, and the recommendation was made for right vertebral artery angioplasty with stenting.  The provider noted she is at increased risk for stroke should she become dehydrated or hypotensive given the carotid occlusion and stenosis of the right vertebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has been recommended to undergo a vertebral artery angioplasty due to vertebral artery occlusion.  The patient underwent left internal carotid artery angioplasty and stenting on 2/27/18 and was noted to have a follow-up on 3/06/18 where she indicated she was doing well. She did complain of one episode of dizziness. While treatment with the requested surgical intervention may be appropriate in certain situations, it does not appear this patient is an appropriate candidate. There is lack of documentation indicating that the stenosis continues to make the patient symptomatic.  The follow-up note indicated the patient was doing well and only had one episode of dizziness.  Given the above, the requested vertebral artery angioplasty is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer  A  55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch and colleagues. There may be some further value in adding the mitotic rate to this system.  As per this system, this patient was staged as T1a, melanoma, with no mitoses seen. This would have an expected ten year survival of at least 88%.  There is no information in the records submitted as to whether she had sentinel node performed. DecisionDX, melanoma assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years).  It is not clear how DecisionDX data compares to the ten year data of the Balch determinations, and whether it can be used to make clinical practice decisions.  This is particularly in question in this patients case given her pathologic findings and excellent prognosis.  All told, DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more effective than other modalities for evaluating this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.