Persius/imr-appeals huggingface dataset:
Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the Epstein-Barr virus is the main etiology of infectious mononucleosis (IM) syndrome that is characterized by fever, sore throat, and lymph adenopathy. Since this virus could be associated with a number of malignancies, some hematologic disorders, and chronic fatigue syndrome, identification of IM is of importance.  The majority of the human adult population is infected with EBV. Usually the infection is well tolerated without any further symptoms after primary infection. In some patients with infectious mononucleosis, or in some who had an infection in their past, it may be important to diagnose symptomatic disease or differentiate infectious mononucleosis from other conditions. In these cases, serological methods, i.e., immunofluorescence, ELISA, or Western blot, are the methods of choice to come to an unequivocal diagnostic conclusion, while the detection and quantification of viral DNA through PCR plays a minor role. ELISA could be applied as a first and preliminary diagnostic test for IM. In addition, this test could be applied in various phases of the disease with a higher sensitivity comparing to PCR. In individuals where EBV infection is associated or causally linked with autoimmune or malignant disease or in patients who have been bone marrow or solid organ transplanted, or in patients with severe immune-suppression, prolonged EBV primary infection or EBV reactivation from latency may be a serious and life-threatening complication. As such, determining the serostatus correctly is important for these patients. However, in this patients case, there was no documentation that this patient had immunosuppression or that she was a transplant patient. In sum, for this patient who presented with lymphadenopathy of unknown origin, PCR testing provided on 5/30/17, was not likely to have been superior over other standard methods of evaluating her medical condition. 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.
Summary Reviewer 




The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the records for the medical necessity of the services at issue in this clinical setting.  Evidence-based assessments are indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The medical literature states that children should be treated in the setting that is least restrictive and disruptive to their lives. More restrictive facilities, like inpatient or residential treatment, are indicated in emergencies or when patients are not responding to efforts at outpatient treatment. In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible to maintain and foster natural supports. This patient did not appear to have adequate treatment progress, and it would not have been safe to treat the patient in a less restrictive setting. The RTC was likely the least restrictive safe setting for this patient after having failed the PHP. Therefore, the mental health residential treatment center services from 11/17/16 through 12/10/16 were medically necessary for treatment of 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 1


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. 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 there is a lack of support for the services at issue in this clinical setting.  There is a lack of prospective controlled data to support random measurement of Remicade/Remicade antibody levels.  The concept of targeted drug level monitoring is supported for several classes of drugs.  However, evidence is lacking for biologic agents in the treatment of this patients condition.  There are multiple variables which drug level monitoring does not consider, thus making this line of testing suboptimal.  For example, the optimal trough level of Remicade remains unknown and likely varies from individual to individual based on unique pharmacokinetics.  Additionally, tissue levels of drug also play an important role.  Therefore, Anser IFX testing performed on 8/17/15 was not likely to have been superior over 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 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. 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 the current medical evidence has not established the superior efficacy of the services at issue.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told, Anser IFX testing performed on 8/17/15 was not likely to be more efficacious 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 3


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. 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 the management of ulcerative colitis using Anser IFX testing has not been standardized, and standardized recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed. The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Per the clinical literature, Anser IFX testing performed on 8/17/15 was not likely to have been of greater benefit 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.
Diagnosis: Clogged feeding tube
 
Treatment: Inpatient admission, interventional procedure

The insurer denied the admission. The denial was upheld.

This case involves patient who presented to the Emergency Department with a clogged percutaneous endoscopic gastrostomy (PEG) tube. The patient was admitted for PEG tube malfunction and had an Interventional Radiology (IR) evaluation.  The patient underwent a removal of the blockage in IR.  The patient was then discharged.

The records failed to support that the patient was unstable or had findings to support the need for inpatient admission. The patient could have undergone the procedure as an outpatient or been placed on observation status.
Diagnosis: Lactic acidosis
 
Treatment: inpatient hospital admission

The insurer denied inpatient hospital admission. The denial was upheld.

This patient is a male who presented with abdominal pain, nausea, and vomiting. He had a blood pressure of 152/103 and a pulse of 109. There was no abdominal rebound or guarding. The white blood count (WBC) was 17.6. The lactate level was 4.4. The patient was reassessed and at that time, the abdominal pain had decreased and the lactate level was normal at 1.2. A CT scan was negative for acute disease. It was felt the patient had cannabis-induced vomiting. The WBC count came down to 12.1. The patient was also found to have poorly controlled diabetes and a hemoglobin A1C of 10. He signed out against medical advice.

According to Milliman Care Guidelines (MCG), clinical indications for admission for vomiting (M-370) include gastrointestinal obstruction, a significant metabolic derangement, severe electrolyte abnormalities, high fevers and acute renal failure. The patient did not have these conditions. He had hypertension and tachycardia on admission but they improved. The lactic acidosis resolved with intravenous (IV) hydration. He was hemodynamically stable. The diabetes was poorly controlled but the patient did not have diabetic ketoacidosis.

This patient had vomiting and lactic acidosis that was attributed to cannabis-induced vomiting. He responded rapidly to IV hydration and the lactic acidosis resolved. The leukocytosis was much improved. IV hydration, Reglan, and Pepcid could have been given with observation status. The patient responded well to the ER treatment. If antibiotics were felt to be needed, they could have been continued orally as an outpatient. He did not meet MCG guidelines for admission for vomiting. The healthcare plan acted reasonably and with sound medical judgment. Inpatient hospital services were not medically necessary.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Diagnosis: Transient ischemic attack/cerebrovascular accident (TIA)/CVA)

Treatment: Livalo 2 milligrams OR tablets

The insurer denied Livalo 2 milligrams OR tablets. The denial was upheld. 

This is a female patient who was seen as an outpatient in her Cardiologist's office in spring of 2019. Two weeks prior to this, she had symptoms consistent with a transient ischemic attack/cerebrovascular accident (TIA)/CVA).  She was admitted to a hospital for a CVA workup, which was negative. The office notes stated that a carotid duplex showed no evidence of carotid artery stenosis.  A venous duplex revealed no evidence of deep vein thrombosis (DVT) and an EKG revealed no evidence of arrhythmia.   Medication history revealed that she was taking atorvastatin 40 mg daily and discontinued it due to leg cramps; she was subsequently started Livalo 2 milligrams daily. Further review of the patient's medications indicated that she discontinued taking Crestor 5 mg daily and Lipitor 40 mg daily due to leg cramps. The conclusion was that there was no hemodynamically significant stenosis of the bilateral lower extremities. 

All FDA-approved statins have been shown to reduce cardiovascular risk; the magnitude of the reduction is related to the magnitude of LDL-C lowering.  Atorvastatin and rosuvastatin at their highest approved doses are the most effective in lowering LDL-C levels and their beneficial effects on clinical outcomes are well-documented.  All of the statins except pitavastatin and pitavastatin magnesium are available generically.  Dosage adjustments are not required with atorvastatin or fluvastatin in patients with severe renal impairment.  Pravastatin, rosuvastatin, and pitavastatin are not metabolized by CYP isozymes and are less likely to interact with other drugs.

Oral pitavastatin (Livalo) is a competitive HMG-CoA reductase for the reduction of elevated total cholesterol and low-density lipoprotein cholesterol (LDL-C) levels in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia. Pitavastatin is an effective treatment option in adults with primary hypercholesterolemia and combined (mixed) dyslipidemia, including those at risk of developing type 2 diabetes.

The carrier's denial of coverage for Livalo 2 milligrams OR tablets is upheld.  The medical necessity is not substantiated.
The patient is a homeless and unemployed male who presented to the emergency department requesting detoxification from alcohol. The patient was using alcohol on a continuous daily basis with approximately five beers daily. He had a longstanding history of alcohol use beginning in adolescence.

The patient provided a history of withdrawal seizures including a seizure two days prior to presentation; he had no history of delirium tremens. Laboratory assessment revealed elevated glucose and evidence of an anemia and malnutrition. Electrocardiogram (EKG) revealed normal sinus rhythm and his chest x-ray revealed borderline cardiomegaly; vital signs were normal. There was no evidence for use of illicit drugs or other drugs of abuse though his urine drug screen was positive for benzodiazepine. The patient was tobacco dependent; he had a history of asthma.

The patient was admitted for inpatient detoxification and other medical services following evaluation and treatment in the emergency department including assessment for safety issues and medical clearance. He had received oral fluid replacement, vitamin replacement, and other supportive measures including resumption of treatment with his usual medication, Keppra.

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient substance abuse treatment  is not medically necessary for this patient.

The proposed treatment and other inpatient medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's alcohol use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol. Moreover, the patient had been evaluated and cleared with regard to safety concerns in the emergency department and did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. Thus, admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario. Any indicated treatment for alcohol use disorder in this case could have been provided, as clinically appropriate, at a lower level of care following the comprehensive assessment and stabilization in the emergency department.
This is a patient who was admitted following medical screening, to acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder. The patient was found in a park and brought to the emergency department; he had eloped and then returned indicating that he had drank all the alcohol he could find with a blood alcohol level of 196. He had laboratory abnormalities that included electrolyte and fluid imbalance and anemia and elevated liver function testing.
The patient reported drinking one pint or more of vodka daily. He presented with moderately severe alcohol withdrawal at the time of admission  including tremor, fatigue, nausea, sweats, headache, irritability, restlessness and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 13 despite having alcohol in his blood. The patient had relapsed after his last detoxification treatment which was one of four previous detoxifications with no past treatment with rehabilitation services and no involvement in recovery groups. He gave no history of withdrawal seizures or past episodes of delirium tremens. He denied use of illicit or prescription drugs, but has a history of cocaine dependence and is tobacco dependent at one-half pack per day.
The health plan's determination is overturned.
The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms and general medical conditions associated with laboratory abnormalities and high risk for withdrawal complications such as seizures. Withdraw symptoms were managed with an Ativan protocol requiring monitoring, as well as comfort medications and vitamin replacement therapy, and continuation of medications to manage his general medical illnesses. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
The patient is a female to male transgender who is requesting coverage of gender confirming mastectomies with free nipple grafting. He began hormone therapy in 2018. On physical examination there are grade 2 ptotic breasts. Coverage was denied for failure to meet age requirement of the coverage criteria.

The health plan's determination is overturned.

Yes, the bilateral mastectomy and nipple reconstruction are medically necessary for this patient.

The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. One of the main functions of WPATH is to promote the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. The SOC are based on the best available science and expert professional consensus. The most recent standards published in 2011 are version 7 and are the current standards of care applied by physicians and surgeons worldwide. Prior to any treatment the criteria requirements are diagnostic and real life experience.
Their Criteria for mastectomy and creation of a male chest in female to male (FtM) patients are:
1) Persistent, well-documented gender dysphoria;
2) Capacity to make a fully informed decision and to consent for treatment;
3) Age of majority in a given country, (earlier preferably after ample time of living in the desired gender role and after one year of testosterone treatment).;
4) If significant medical or mental health concerns are present, they must be reasonably well controlled.
In this case their criteria have been met because he has lived as a male and been on hormone therapy for over a year, there are no other significant medical or mental health concerns, and the gender dysphoria is well documented and persistent.