Persius/imr-appeals huggingface dataset:
Summary Reviewer 

The patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regards to risk of harm, the records support a score of 4. The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center. In terms of functional status, the records support a score of 3. The records noted 
moderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission. With regard to comorbidity, the records support a score of 3 due to the physical manifestations of anorexia nervosa, including low weight and laboratory abnormalities, co-occurring with post-traumatic stress disorder, depression, and anxiety symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to discord with parents and recent transition back to the United States after a year of living abroad. With regard to level of support of the recovery environment, the records support a score of 3 due to parents ambivalence toward participating in treatment and lack of recent contact with the patient. In terms of treatment and recovery history, the records support a score of 4 due to the persistence of symptoms despite prior extensive treatment. With regard to engagement and recovery status, the records support a score of 3 due to poor insight and limited judgment. Thus, the patient has a composite score of 23. In this case, the records support medically monitored residential services. Therefore, eating disorder residential treatment center services from 1/23/20 forward were and are medically necessary for the treatment of this patient.
Summary Reviewer 2

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. 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 that the non-surgical treatment is the initial treatment of choice for symptomatic hallux valgus deformity. Shoe modification, padding and local application of ice to symptomatic bunion are reasonable initial conservative options. Orthotic devices to control documented biomechanical dysfunction may be considered as conservative or post-surgical options. Surgical treatment is recommended if there is no or little response to non-operative treatment after a six-month trial, or if initial response deteriorates. In general, once surgical criteria has been met, the surgical procedures to be performed are based on the location and the degree of deformity. The two most common radiographic measurement used to choose appropriate surgical procedures include the intermetatarsal angle (IMA) and the hallux valgus angle (HVA). For IMAs less than 13 degrees, distal osteotomy or soft tissue procedure alone are sufficient to correct the deformity. For IMAs greater than 13 degrees, a proximal osteotomy is recommended. There is a variety of osteotomies described to correct the IMA, including the scarf, and no procedure has proved superiority over the other. Regarding the HVA, angles less than 30 degrees can be treated with a distal soft tissue procedure, such as the modified McBride procedure, with or without a chevron osteotomy. For HVA greater than 40 degrees, metatarsophalangeal joint fusion is generally recommended.
In this patients case, operative criteria have been met. Based on the radiographs and the HVA and IMA measurements reported by the treating surgeon, appropriate surgical procedures were performed and are supported by published treatment guidelines for the treatment of symptomatic hallux valgus. In sum, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Summary Reviewer 


A 60-year-old male enrollee has requested reimbursement for chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spondylosis without myelopathy/radiculopathy of the cervical region. The physician reviewer found that the provided documentation does not establish the medical necessity of the chiropractic services provided from 6/1/17 through 9/7/17. Specifically, the records do not objectively verify functional improvements with prior chiropractic therapy over eight weeks of care. As noted in the current medical literature and guidelines, the documentation should report objective functional improvement with chiropractic treatment to support an indication for future services. Accordingly, the chiropractic services including CPT codes 97110, 97032, 97140 and 99214 provided on 6/1/17, 6/8/17, 6/15/17, 8/14/17, and 9/7/17 were not medically necessary for treatment of this patients neck pain and low back pain. 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 

A 55-year-old female enrollee has requested reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value. In this circumstance, a period of overnight observation without hospital admission is reasonable and appropriate to confirm no evidence of myocardial infarction with serial troponins prior to discharge. Since the patient was clinically stable after initial evaluation, with an anticipated length of stay of less than 48 hours or less than two midnights, hospital admission was not medically necessary. Based on the records, an observational level of stay would have been safe and effective. Thus, inpatient hospital services provided from 3/01/18 through 3/02/18 were not medically necessary for the treatment of this patient. Therefore, 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 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.The physician reviewer found in this case, the medical records fail to indicate any diagnosis consistent with an IgG mediated food allergy to support an indication for the testing at issue. The current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated (Boyce, et al). The Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated (Sampson, et al). As such, IgG food testing is not considered the standard of care in this clinical setting (Sicherer and Teuber). Thus, the IgG food sensitivity testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.  The physician reviewer found the use of food-specific IgG level testing has not been shown to improve health outcomes at long-term follow-up. There is data suggesting that this testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods (Beyer and Teuber). Thus, food-specific IgG should not be used as a tool to diagnose food allergy and the positive foods should not be eliminated from the diet based upon results of these tests (Lemon-Mule, et al; Savilahti, et al). The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens including egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95% predictive accuracy. In conclusion, the IgG food laboratory testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard of care.Based upon the information set forth above, the testing at issue was 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 1


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found there is sufficient support for the service at issue in this clinical setting.  Skaane and colleagues noted the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues indicated integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed on 5/23/16 was likely to have been of greater benefit 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  
The patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including 
on her palms and soles. The patient has requested authorization and coverage for Cosentyx two 
pens 150 mg/ml pen injector. The Health Insurer has denied this request and reported that the 
requested medication is not medically necessary for the treatment of this patient. This denial is the 
subject of this appeal and determination. The physician reviewer found Cosentyx is a U.S. Food 
and Drug Administration (FDA) approved medication for the treatment of psoriasis.  It receives 
an A rating from the American Academy of Dermatology and National Psoriasis Foundation 
guidelines of care. This medication has good safety and efficacy profiles. It is recommended as 
treatment for chronic psoriasis by the American Academy of Dermatology and National Psoriasis 
Foundation. It has been shown in the FIXTURE study to be a safe and efficacious medication for 
the treatment of psoriasis. The requested medication is medically indicated for the treatment of 
this patients chronic psoriasis, psoriatic arthritis and hand and foot psoriasis. Therefore, Cosentyx 
two pens 150 mg/ml pen injector is medically necessary for the treatment of this patient.
Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients symptoms on 12/1/16 did meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics. The medical records support a comprehensive history and medical decision making of high complexity to support CPT code 99285. The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged. All told, the emergency department services provided at Hoag Hospital on 12/1/16 were required on an emergent basis and include comprehensive history and medical decision making of high complexity to support CPT code 99285. Therefore, the Health Insurers denial should be overturned.
Summary Reviewer 

The patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient does not have any chronic medical conditions that would cause vitamin D deficiency. She did not have any signs or symptoms of vitamin D toxicity or severe deficiency. Therefore, vitamin D testing performed on 7/30/19 was not medically necessary for the evaluation of this patient.
Summary Reviewer 1


A 51-year-old female has requested reimbursement for human epididymis protein 4 (HE4) testing.  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 sufficient support for the services at issue in this patients case.  HE4 is used for the evaluation of an adnexal mass as a component of the Risk of Ovarian Malignancy Algorithm (ROMA). A ROMA score helps determine the likelihood that an adnexal mass is malignant and the need for referral to a gynecologic oncologist for surgery. This testing is considered a standard of care.  In sum, HE4 testing performed on 11/20/15 was 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 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 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patient has received Prolia.  In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) scan is appropriate to monitor therapy.  The value of monitoring therapy with the use of biochemical markers of bone turnover is controversial.  This is a test that can be variable and subject to timing, dietary intake and lack of assay standardization.  In sum, collagen crosslink testing performed on 7/11/15 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.
Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for CPT 19316 performed on 10/24/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had evidence of significant symptomatic macromastia, and she had failed conservative management. Based on the documentation provided, she was a candidate for bilateral breast reduction based on non-resolving functional impairment. She underwent this procedure on 10/24/18. The operative note was consistent with a standard breast reduction and not solely a mastopexy. Generally, standard breast reductions include a breast lift as an integral part of the procedure and would not be considered a separate procedure. Based on the documentation provided, this patient underwent a bilateral breast reduction and not solely a mastopexy. An additional mastopexy would not be considered as a separate procedure, but an integral portion to the breast reduction. Therefore, the Health Insurers denial was appropriate. Thus, mastopexy (CPT 19316) performed on 10/24/18 was not medically necessary for the treatment of this patient.
Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy. The physician reviewer found that placement of a prophylactic defibrillator is not recommended until a period of time after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment (Russo, et al). Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Steinbeck, et al). A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. Therefore, the Life Vest provided from 6/10/15 through 7/10/15 has not been demonstrated by scientific literature as likely to have been more beneficial in treating this patients medical condition than standard alternatives. Based upon the information set forth above, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 2

A 47-year-old male enrollee has requested reimbursement for the Oncotype Dx Colon Cancer Assay provided on 2/14/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectosigmoid cancer. The physician reviewer found that the Oncotype DX test uses a reverse transcriptase polymerase chain reaction assay for 12 genes in an algorithm that can be used to help predict recurrence (OConnell, et al; Gray, et al). Despite this support, it has not been established whether adjuvant chemotherapy can obviate recurrence risk. Overall, the current data does not support use of the Oncotype DX as a predictive marker for response to adjuvant treatment (Benson and Hamilton; Gray, et al). As such, the National Comprehensive Cancer Network (NCCN) guidelines state that there are insufficient data to recommend use of multi-gene assay panels to determine adjuvant therapy. All told, the Oncotype DX Colon Cancer Assay provided on 2/14/18 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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.