Persius/imr-appeals huggingface dataset:
Summary Reviewer 3
A 58-year-old female enrollee has requested reimbursement for the DecisionDX uveal melanoma (UM) multigene assay performed on 4/10/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees intraocular choroidal melanoma of the left eye. The physician reviewer found that the service at issue was likely to be more effective than other methods of evaluating this patient. This patient has a rare disease, ocular melanoma.  However, knowledge of the propensity for metastasis directly affects surveillance of patients by computed tomography scan. Along these lines, there are clinical studies that support the use of gene expression classifier DecisionDX uveal melanoma. This assay defines two classes of ocular melanoma. Class 1 is associated with a low risk of metastasis and class 2 has a 50% risk at two years and 72% risk at five years. Currently, there is no other standard prognostic indicator that could serve as an alternative. Thus, the current medical evidence favors the use of this test in the post-operative surveillance of patients with ocular melanoma. As such, the DecisionDX uveal melanoma multigene assay performed on 4/10/15 was likely to be superior over other available 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 30-year-old male with a history of gynecomastia. Therefore, the patient has requested authorization and coverage for suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303). 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 case was previously reviewed, and additional documentation was submitted for reconsideration. Additional medical information received for review included an email from the provider indicating that a surgical facility charges for liposuction for time and supplies, and there would still be a charge even if he charged no professional fee.  On 5/09/20, the provider noted, aThe bilateral breasts demonstrate Simon Grade IIa gynecomastia. There are tender subareolar masses bilaterally measuring approximately 2 cm x 3 cm x 3 cm.a He also reported that the patient adesires surgical excision of gynecomastia in addition to potential suction lipectomy.a The American Society of Plastic Surgeons reports the following gynecomastia scale adapted from the McKinney and Simon, Hoffman and Kohn scales: grade I a small breast enlargement with localized button of tissue that is concentrated around the areola; grade II - moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest; grade III -moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present; grade IV - marked breast enlargement with skin redundancy and feminization of the breast. In this case, photographs demonstrate chest enlargement that significantly exceeds the 2 cm x 3 cm x 3 cm size of the glandular tissue, so that the chest enlargement constitutes mixed gynecomastia, with a mixture of both true glandular gynecomastia and fatty tissue constituting pseudogynecomastia. There is no change in determination that liposuction is an optional surgical technique that can be used during gynecomastia surgery and is not a separate surgical procedure for the patient for treatment of gynecomastia. Liposuction of the chest area well beyond the limited area of the gynecomastia excision can be performed for improved cosmetic appearance, particularly when the gynecomastia is mixed and there is some degree of pseudogynecomastia present. Liposuction for that purpose would be cosmetic and not medically necessary. Thus, suction assisted lipectomy trunk (CPT 15877) is not medically necessary as a separately billed procedure. CPT 19303 is not medically necessary because it applies to a mastectomy in a woman. In sum, suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303) are not medically necessary for the treatment of this patient. The Health Insurer has approved the appropriate CPT code in this case (CPT code 19300).
Summary Reviewer 


A 64-year-old female enrollee has requested authorization and coverage for Harvoni for 24 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. In the ION-2 study, 440 HCV patients underwent randomization and were treated, 20% had cirrhosis and 79% had HCV genotype 1a infection. The rates of sustained virologic response were high in all treatment groups. There was a 99% (95% confidence interval (CI), (95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and 99% (95% CI, 95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and ribavirin (Afdhal, et al). The results of an abstract were presented at the American Association for the Study of Liver Diseases Liver Meeting. In this double-blind study, Bourliere and colleagues randomized 155 patients previously unable to achieve SVR after sequential treatment with a peginterferon and ribavirin regimen followed by a protease-inhibitor (PI), peginterferon  and ribavirin regimen, to undergo treatment with ledipasvir/sofosbuvir and ribavirin placebo for 24 weeks or matching placebo for 12 weeks, followed by ledipasvir/sofosbuvir and ribavirin for 12 weeks. Patients were stratified by HCV subtype and their responses to their most recent therapy. Of the 77 patients treated with ledipasvir/sofosbuvir and ribavirin for 12 weeks, 4% experienced relapse; compared with 3% of the 77 patients treated with ledipasvir/sofosbuvir for 24 weeks, for a 3% total incidence of relapse. Based on the peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 

The patient is a 20-year-old female who has been diagnosed with posttraumatic stress disorder,
major depressive disorder, generalized anxiety disorder, and alcohol use disorder.The
patient has requested reimbursement for mental health residential treatment provided from 3/22/20
through 5/22/20. The Health Insurer has denied this request and reported that the services at issue
were not medically necessary for the treatment of this patient.The physician reviewer found the mental health residential
treatment provided from 3/22/20 through 5/22/20 was medically necessary for the treatment of this
patient.
Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient has already undergone great saphenous vein removal.  The reflux from the incompetent saphenofemoral junctions is now going down the accessory saphenous veins.  These veins are very large, and have free reflux.  They are essentially acting as refluxing greater saphenous veins. In the situation where these veins can be ablated, this treatment is standard of care.  All told, the requested ablation of varicose veins, right and left accessory ablation is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 2
A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Patients with anterior accessory saphenous vein reflux and patients with the great saphenous vein reflux demonstrate similar disease-specific features.  Following great saphenous veins ablation, persistent non-refluxing branches do not appear to have an adverse impact on clinical outcome two years after successful ablation of the great saphenous vein.  Although there is limited clinical data to recommend ablation of the non-axial veins, the published data suggest it is effective in selected patients.  There is evidence to support sclerotherapy in the treatment of accessory recurrent varicose veins following ablation.  Thus, ablation of varicose veins, right and left accessory ablation is likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 3


A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that while endovenous ablation of the greater saphenous vein has been extensively evaluated in the treatment of varicose veins, little is known about the efficacy in the treatment of accessory saphenous veins.  Furthermore, patterns of recurrence of varicose veins after greater saphenous vein treatment is usually new reflux in the accessory saphenous vein and there is little evidence available to guide optimal therapy, in contrast to greater saphenous vein interventions.  Therefore, given the absence of evidence for the efficacy of endovenous ablation of accessory saphenous veins after surgical therapy of greater saphenous vein incompetence, the superior effectiveness of the requested services has not been established.  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 

The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential services provided from 1/10/18 through 4/20/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees 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. On 12/29/17, the documentation noted that the patient had purchased knives and a taser gun. However, these records are from admission. The records for the disputed timeframe indicated evidence of low risk of harm. Additionally, this note had minimal objective evidence. This record does not document that violent acts or self-harm were committed. In terms of functional status, the records support a score of 2. The patient has demonstrated episodic failure to achieve expected levels of functioning in relationships with family and peers. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or active substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. With regards to level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. It appears that the patients major depression symptoms were under good control with minimal signs or symptoms. He continued to have oppositional behaviors. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient was able to establish positive relationships with clinicians despite oppositional behaviors. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential services provided from 1/10/18 through 4/20/18 were not medically necessary for the treatment of this patient.
Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for emergency services provided on 1/26/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the 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. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented for removal of scalp sutures due to a laceration nine days prior to her visit. She admitted to a lingering hangover feeling, but had no specific complaints of headache, vomiting, dizziness, blurry vision, or other symptoms of acute head injury. She denied any symptoms of wound infection. Moreover, the patient was not experiencing the sudden onset of acute symptoms. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/26/16 did not meet prudent layperson criteria for emergency care.
Summary Reviewer

The patient is a 57-year-old female with severe osteoporosis. As part of the work-up her endocrinologist ordered a parathyroid scan to rule out a parathyroid adenoma. The patient has requested authorization and coverage for parathyroid planar imaging. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary. The records provided for review indicate that this patient has severe osteoporosis and further evaluation for a parathyroid adenoma (primary hyperparathyroidism) is appropriate. However, the medical literature suggests that the diagnosis should be made with biochemical markers showing the combination of hypercalcemia and an elevated or inappropriately normal parathyroid hormone (PTH) level. Measured total serum calcium should be adjusted for albumin. If the corrected serum calcium is normal and PTH is elevated, serum ionized calcium should be measured, as primary hyperparathyroidism can present with an elevated ionized calcium despite a normal albumin-adjusted serum calcium (Khan, et al). The standards of care also indicate that parathyroid scan is appropriate when a decision to remove a parathyroid adenoma has been made (Khan, et al; Bilezikian, et al; Pallan, et al). Overall, parathyroid imaging is not a diagnostic procedure and is not advised unless surgical intervention is planned. The value of imaging rests with accurate identification of abnormal parathyroid tissue in order to assist in planning the appropriate parathyroid surgery (Khan, et al). In this case the diagnosis of primary hyperparathyroidism has not been established. The laboratory tests performed on 10/26/17 show normal calcium, mid-normal intact PTH level at 36 and normal ionized calcium and phosphorus. The patients 25 vitamin D and 1, 5 vitamin D levels are normal, and urinary calcium is normal. In January 2018, the patient had two normal calcium levels and intact PTH. As the patient does not have biochemical evidence of primary hyperparathyroidism, the requested parathyroid planar imaging is not medically necessary for evaluation of this patients medical condition.  Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer  
The patient is a 59-year-old male who presented with hematochezia in August 2021. The patient 
has requested authorization and coverage for PET imaging with concurrent CT skull base to mid-
thigh. The physician reviewer found that there is sufficient support for the requested services in 
this clinical setting. According to the National Comprehensive Cancer Network (NCCN) guidelines, 
PET/CT has a limited sensitivity but high specificity, and may be considered when there is an 
equivocal finding. When hepatocellular carcinoma is detected by CT or magnetic resonance 
imaging (MRI) and has increased metabolic activity on PET/CT, higher intralesional standardized 
uptake value (SUV) is a marker of biologic aggressiveness and might predict less optimal response 
to  locoregional  therapies.  Sensitivity  is  a  metric  for  the  screening  of  cancer,  but  for 
discriminating responses, the specificity may be most relevant.  The original disease showed 
significant FDG uptake. There were multiple sites of disease making the interpretation of follow-
up imaging very complex. The use PET/CT is medically necessary for further care. Therefore, the 
requested PET imaging with concurrent CT skull base to mid-thigh is medically necessary for the 
evaluation of this patient.
Summary Reviewer 1

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 there is a lack of support in the medical literature for the services at issue in this clinical setting. The medical literature indicates that Epstein-Barr virus (EBV) is the main etiology of infectious mononucleosis syndrome associated with lymphadenopathy. The main methods of evaluation include PCR testing and testing by ELISA for the viral capsid antigen. Quantitative PCR testing may be indicated for the following EBV evaluations: EBV viral load, to monitor for EBV viral replication in hematopoietic stem cell and solid organ transplant recipients. More frequent testing is worth considering if the EBV load is rising. However, for standard risk individuals, as this patient, testing should be done only when they are suspected to have EBV infection. The submitted documentation does not support that this patient had a medical indication to have warranted the PCR testing. Accordingly, PCR testing provided on 5/30/17 was not likely to have been of greater benefit than the standard therapy available for evaluating this patients 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 2

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 patient has had a history of enlarged lymph nodes of unknown etiology. She has had a biopsy and blood tests, which were all negative. She had a PCR test Epstein-Barr virus and other organisms. The common testing performed for lymphadenopathy can generally determine the cause of the lymphadenopathy. The test results for this patient were normal but she continued to have large lymph nodes. A PCR test to detect the cause of the lymphadenopathy is within the standard of care to evaluate uncommon etiologies of large lymph nodes such as in this patients case when all standard first step work up have been negative. As such, PCR testing provided on 5/30/17 was likely to have been more effective than the available standard techniques for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.