Persius/imr-appeals huggingface dataset:
Summary Reviewer 1


A 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this patients case.  The records do not demonstrate that a specific genetic condition is suspected by the requesting provider.  In the absence of a proposed diagnosis, there is insufficient evidence that this testing will change management or improve health for this patient.   In addition, given the early state of this technology, the implications of many genetic mutations are not currently known.  For these reasons, the requested services are not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although DecisionDx Melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. For this reason, the DecisionDx Melanoma testing (CPT code 84999) performed on 1/23/17 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 


The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 2/06/13 through 5/03/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this case, the patient was struggling with the developmental stage of identity formation which was complicated by a formidable anxiety and affective burden coupled with an underdeveloped sense of self and substance use which fueled dysphoria and parent-child disharmony.  The documentation provided does not support the medical necessity of the services at issue during the disputed timeframe.  It appears as though the patient and his family had not pursued evidence-based treatments in a less restrictive setting during the episode of illness.  Such interventions include, but are not limited to, school-based services, psychotherapy, chemical dependency counseling, family therapy, parent training and pharmacotherapy.  Additionally, the medical records did not include a psychiatric evaluation, psychosocial assessment, history and physical examination, or integrated summary justifying the necessity of the placement as opposed to a lower level of care.  The discharge summary, psychological evaluation and initial treatment plan did not describe behaviors, symptomatologies, or treatment interventions that would typically require a 24-hour supervised setting.  In sum, the documentation submitted for review did not suggest that a less restrictive setting would have been insufficient.  All told, residential treatment provided from 2/06/13 through 5/03/13 was 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 2

A 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found the Decision Dx melanoma assay examines genes for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy in thin melanomas. However, the patients treatment would not likely change based on the results of the exam. There is a lack of medical literature to support its use in patients with thin melanomas to effect health outcomes. Given the lack of published data to support the use of gene expression profiling, the testing performed on 6/29/16 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 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested medication. There has been a diagnosis of peripheral motor polyneuropathy. Medical records from his neurologist describes muscular atrophy and weakness, diminished distal reflexes, and no upper motor neuron signs. Headaches and autonomic dysfunction are also described. He has had treatment with Radicava, which is indicated for treatment of amyotrophic lateral sclerosis. The notes do not include electromyography/nerve conduction velocity studies or autoimmune studies. Based on the available records, the diagnosis is unclear. While motor neuropathy is commonly treated with intravenous immune globulin, there is a lack of evidence that intravenous immune globulin would be helpful for amyotrophic lateral sclerosis. Without a more distinct diagnosis, it is not possible to state that intravenous immune globulin is likely to be more effective than other therapies. Thus, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is not likely to be more beneficial than other treatment options.
Summary Reviewer 

The patient is a 36year-old female with a history of low back and right lower extremity pain due to a disc herniation at L4-5.  The patient has requested reimbursement for anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Phan and colleagues performed a meta-analysis of seven studies, including 181 patients who underwent anterior lumbar discectomy and fusion after primary discectomy had resulted in a recurrence of low back and leg pain, as in this patients case. The authors noted that there are certain advantages to the anterior approach. Repeat posterior approach for recurrent herniations may result in trauma to the spinal nerves and paraspinal muscles that is avoided in the anterior approach. Furthermore, the authors noted that the exposure allows for a comprehensive discectomy. In these 181 patients, there was significant improvement in the Oswestry Disability Index and Visual Analogue Scale (VAS) back and leg pain scores. The average length of hospital stay was 5.28 days. This patient has requested reimbursement for the surgery and two days of inpatient hospitalization. The authors concluded that anterior lumbar interbody fusion is a feasible approach for the treatment of recurrent lumbar disc herniations and demonstrates good results, with minimal complications. As such, in the presence of a recurrent herniation with chronic low back and leg pain, and failure of conservative treatment, the services at issue were medically indicated. Therefore, the anterior interbody fusion with cage lumbar disc L4-5 performed on 4/23/21 and two days of inpatient hospitalization were medically necessary for the treatment of this patient.
Summary Reviewer 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. This patient had a low annual growth velocity which indicated abnormal growth. His estimated adult height gradually declined to 66 inches, which indicates poor growth. His estimated adult height is below his genetic potential of 71.6 inches. Per the records, he failed growth hormone stimulation testing with a peak less than 10ng/mL, which indicates growth hormone deficiency in the setting of poor growth. Therefore, Humatrope 24 mg cartridge is medically necessary for the treatment of this patient.
Summary Reviewer 

The patient is a 44-year-old female who presented to the emergency department on 10/13/19 with complaints of abdominal pain status post dirt bike accident. At the time of presentation, her vital signs were stable, with a heart rate of 112 and normal oxygen saturations on room air. The physician reviewer found that in this case, the patient was admitted in stable condition. Her pain was controlled with oral pain medications. She did not require any urgent surgery or procedures. Her vital signs were stable, and there was no evidence of hemodynamic instability or active bleeding. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting,
when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient admission provided from 10/13/19 through 10/14/19 was not medically necessary for the treatment of this patient.
Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for laparoscopic gastric sleeve (CPT 43775) performed on 12/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  This patient is an adult with morbid obesity.  Per the records, her body mass index was greater than 40 kg/m2 (it was 44.9 kg/m2). The patient documented prior dietary efforts and completed a multidisciplinary evaluation that did not reveal any obvious medical, dietary or behavioral barriers to surgery. The patient met standard nationally accepted criteria for bariatric surgery.  The current medical evidence supports the services at issue in this clinical setting.  All told, laparoscopic gastric sleeve performed on 12/17/15 was medically indicated 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 

An 18-year-old female enrollee has requested reimbursement for mental health residential treatment from 7/17/17 through 9/16/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation and attempts. In terms of functional status, the records support a score of 2. The patient has had some issues with level of functioning, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems and reported a history of mild cannabis use issues.  She did not describe continued cravings, and there was no documentation of withdrawal symptoms from substances. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family as a focus of treatment. However, the progress notes document that her family therapy sessions were productive and not adversarial. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. The patient had good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. She had a history of residential treatment in the past, and it is not clear that her symptoms resolved with past treatment efforts. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively and was able to develop a positive relationship with clinicians. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 17. This score correlates intensive outpatient services. Therefore, mental health residential treatment provided from 7/17/17 through 9/16/17 was not medically necessary for the treatment of this patient.
Summary Reviewer 2


A 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found Currently, that there is a lack of clinical data in the medical literature to indicate the superior efficacy of the requested services when compared to conventional treatment options. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT).  A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. Also, the ASTRO emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials, (Allen, et al). Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer.  The patients previous history of treatment with radioactive iodine does not preclude the use of standard treatment with photons. Therefore, proton therapy is not likely to be more effective than standard therapy in the treatment of this patients medical condition. 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 1

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that in this case, the patient had severe dysphagia with an inability to tolerate solid food intake and a hiatal hernia, with upper gastrointestinal series showing reflux. Hernia repair surgery was being contemplated before the endoscopy with pH study. This is consistent with current medical literature, which recommends a pH study to evaluate esophageal motility before undergoing such a surgery. Additionally, dysphagia in the setting of dilated and angulated esophagus can be suggestive of achalasia, and warrants evaluation with impedance and with esophagogastroduodenoscopy. Furthermore, esophagogastroduodenoscopy is recommended for the evaluation of dysphagia. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was likely to have been more beneficial than any available standard therapy.
Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for DecisionDX Melanoma gene expression assay performed on 12/23/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found there is a lack of high-grade scientific data to support the superior efficacy of the services at issue in this clinical setting. The DecisionDX Melanoma gene expression assay has not been clinically shown to add to the current standard of care for the evaluation of malignant melanoma. Therefore, the DecisionDX Melanoma gene expression assay performed on 12/23/15 was not likely to be more effective than standard treatment for the evaluation of 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 1 
 
The parent of a seven-year-old female enrollee has requested authorization and coverage for 
Xeljanz 5 mg tablet. The Health Insurer has denied this request and reported that the requested 
medication is investigational for the treatment of the enrollees alopecia. The physician reviewer 
found that the U.S. Food and Drug Administration (FDA) approves the use of one Janus kinase 
(JAK) inhibitor, Olumiant (generic name baricitinib), for the treatment of adult patients with 
severe alopecia areata. Pediatric-onset alopecia areata, including alopecia universalis, tends to 
be more severe and carries a worse prognosis than adult-onset disease. While there are no FDA 
approved treatments for alopecia areata in pediatric patients, current medical literature supports 
the use of oral JAK inhibitors, such as Xeljanz, as resulting in an improvement of Severity of 
Alopecia Tool (SALT) scores. Kennedy Crispin and colleagues report that tofacitinib is a safe and 
effective treatment for severe alopecia areata. Toussi and colleagues note that alopecia areata 
has substantial psychosocial impact on patients and results in reduced health-related quality of 
life, which should be addressed as an active part of treatment. In this case, given the patients 
response to Xeljanz, including hair regrowth and improvement of psychiatric comorbidities, the 
requested medication is likely to be more beneficial than the several other treatments that she 
has already tried and failed. Therefore, Xeljanz 5 mg tablet is likely to be more beneficial for 
treatment of the patients condition than any available standard therapy.
Summary Reviewer 

The patient is a 57-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland. The patient has requested authorization and coverage for intensity modulated radiation therapy image-guided radiation. 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 requested services are standard of care in this clinical setting. High-quality clinical outcomes published in the peer-reviewed medical literature have proven that aggressive consolidation of oligometastatic prostate cancer is associated with a significant improvement in chances for long-term survival. The high-quality prospective trial by Parker and colleagues supports such a benefit, as definitive radiotherapy improved failure-free survival. IMRT is widely employed nationwide for similar patients in this setting. Therefore, intensity modulated radiation therapy image-guided radiation is medically necessary for the treatment of this patient.
Summary Reviewer 2

A 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that current evidence-based medical literature supports the use of autologous chondrocyte implantation as a first-line treatment option for large articular cartilage defects. The literature supports treatment with bone marrow stimulation for lesions of smaller sizes, whereas treatment with autologous osteochondral transplantation may be utilized for larger or cystic lesions. The literature indicates that autologous chondrocyte implantation of the talus yields improvement in all parameters tested, with enduring long-term results in patients who have failed previous surgery for osteochondral lesions of the talus. This patient presents with a history of chronic severe right ankle pain and swelling. Significant functional limitations are noted that interfere with activities of daily living. There is imaging evidence of a very large cystic osteochondral lesion of the right talus. She has failed long-term conservative management as well as operative intervention. She is not a candidate for microfracture surgery due to the size of the lesion. Current evidence-based medical literature supports the use of autologous chondrocyte implantation in this clinical setting as a salvage procedure. In sum, autologous chondrocyte implantation is likely to be more beneficial than other treatment options.