Persius/imr-appeals huggingface dataset:
Summary Reviewer 2


A 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.   The physician reviewer found that the available records document that this patient has mild facet arthropathy as demonstrated on magnetic resonance imaging (MRI) as well as having discogenic radiculopathy. However, the medial branch blocks performed on 8/4/15 are not indicated in the presence of another clear cause of the patients low back and radicular pain. Further, the use of repeated diagnostic blocks absent a plan for radiofrequency neurolysis is not consistent with clinical practice guidelines. Thus, the in-office surgical injections performed on 8/4/15 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 66-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the concept of following drug levels when using tumor necrosis factor (TNF)-alpha antibodies to provide personalized dosing has been around for many years. Following drug levels can keep a patient at a target level which translates into a higher probability of clinical benefit. This concept is based primarily on retrospective data which has demonstrated that, in general, higher trough levels correlate directly, and the presence of antibody correlates indirectly, with clinical efficacy. Knowledge of the drug and antibody level would therefore assist the provider in the decision to increase a drugs dose or perhaps switch to another class of biologics. However, this approach has not been shown to be superior to making empiric changes. There is a lack of controlled data which have identified the optimal drug level. A recent trial demonstrated this approach had no impact on clinical efficacy compared to empiric dose titration (Steenholdt, et al). Therefore, the unlisted chemistry procedure (84999) Prometheus Anser testing performed on 12/22/15 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 2

A 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that there is sufficient support for the requested services in this case. This patient has lateral nasal wall collapse from lower lateral cartilage weakness. The images appear to show significant collapse. The Latera implant is a U.S. Food and Drug Administration (FDA) approved device which has been used successfully for lateral nasal wall collapse. In sum, vestibular stenosis repair 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  
 
The patient is a 42-year-old female with a history of treatment resistant, recurrent major 
depressive disorder. The patient has requested reimbursement and prospective authorization 
and coverage for adult mental health transcranial magnetic stimulation provided from 10/15/21 
forward. The physician reviewer found that per the medical literature, transcranial magnetic 
stimulation is indicated for severe, recurrent major depressive disorder that has not responded 
to traditional medication and psychotherapy treatment.  This patient qualifies for the diagnosis 
of treatment refractory depression given her two failed antidepressant trials in addition to 
psychotherapy.  This  patient  had  also  tried  electroconvulsive  therapy.  She  completed  five 
treatments but could not tolerate the confusion and headaches.  Additionally, she was evaluated 
by a psychiatrist who recommended transcranial magnetic stimulation at this point in her 
treatment. Based on the records, transcranial magnetic stimulation was the appropriate next 
step  in  treatment  for  this  patient.  Therefore,  adult  mental  health  transcranial  magnetic 
stimulation provided from 10/15/21 forward was and is medically necessary for the treatment of 
this patient.
Summary Reviewer 


A 65-year-old male enrollee has requested authorization and coverage for Rytary. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Parkinsons disease. The physician reviewer found that the submitted documentation fails to support the medical necessity for the requested medication. While Rytary is a medication that is commonly used for the treatment of patients with Parkinsons disease, it is prescribed after the patient has tried and failed extended release formulations. The documentation provided do not demonstrate that this has been administered in this patient.  The patient has not been placed on extended release formulations of carbidopa/levodopa. As such, it would be appropriate for the patient to try the extended release formulations prior to being started on Rytary. Accordingly, Rytary is not currently medically necessary for treatment of this patient.  Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1

A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue such as this patient. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and overall increase in diagnostic accuracy compared to two-dimensional imaging alone. The medical evidence supports the service at issue in this clinical setting. All told, breast tomosynthesis performed on 3/15/17 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 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patientas parent has requested reimbursement for occupational and speech therapy services provided from 7/24/20 through 8/20/20. 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 that the submitted documentation supports the medical necessity of the services at issue. The patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. Spittle and colleagues compared the effectiveness of early developmental intervention program provided post hospital discharge to prevent motor or cognitive impairment in preterm infants versus standard medical follow-up of preterm infants at infancy, preschool age, school age, and adulthood. The authors noted, aInfants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants.a Spittle and colleagues noted, aEarly intervention programs for preterm infants have a positive influence on cognitive and motor outcomes during infancy, with cognitive benefits persisting into preschool age.a Woodward and colleagues stated that infants born before 34 weeks of gestation have three times the risk of impairments in multiple developmental domains compared with term infants. Bui reported, aPreterm children should be screened regularly for developmental delay, and parents of preterm infants should be counseled about the options of early intervention programs, and their potential positive impact on development.a In an article describing the importance of physical, occupational and speech therapy for infants born prematurely, Orton and colleagues noted, aThe developmental allied health team, consisting of physical therapy, occupational therapy, and speech pathology, is crucial in early evaluation of gross motor, fine motor, feeding, and language development. Surveillance of neurodevelopment in the first year of life is essential to ensure early detection of specific developmental delays and impairments, and to ensure timely referral for early intervention. Early intervention is not only important in optimizing long-term outcomes for the child, but it also plays an important role in enhancing the parent-child relationship and parental well-being.a The medical evidence supports the services at issue in this clinical setting. Therefore, occupational and speech therapy services provided from 7/24/20 through 8/20/20 were medically necessary for the treatment of this patient.
Summary Reviewer 


A 31-year-old male enrollee has requested authorization and coverage for anastrozole 1 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is being treated for testicular hypodysfunction with testosterone and human chorionic gonadotropin.  The laboratory studies from November 2015 and February 2016 show normal or high values of testosterone.  For men who are hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning serum testosterone concentration on three separate occasions, testosterone replacement therapy is recommended. The approved uses for anastrozole 1 mg include first-line treatment of locally-advanced or metastatic breast cancer (hormone receptor-positive or unknown) in postmenopausal women, adjuvant treatment of early hormone receptor-positive breast cancer in postmenopausal women or treatment of advanced breast cancer in postmenopausal women with disease progression following tamoxifen therapy.  In this case, the patient does not have an approved indication for the use of anastrozole.  Furthermore, this medication is not recommended for the use of testicular hypofunction.  The documentation supports that the patient has had improved symptoms while taking testosterone and human chorionic gonadotropin.  Thus, the requested anastrozole 1 mg is not medically indicated for the treatment of this patient.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1

A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter closure pressure, but allow for food passage with swallowing. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time that pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study comparing the LINX procedure with laparoscopic fundoplication was performed by Reynolds and colleagues. The authors found that gastroesophageal reflux disease patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Therefore, the LINX Reflux Management System (code 43284) and one inpatient day are likely to be superior over other treatment options.
Summary Reviewer 3


A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that the patient has a history of persistent AF and has required cardioversions. She is now on antiarrhythmic drug therapy with dronedarone.  According to the guidelines endorsed by the American College of Cardiology, American Heart Association and the Heart Rhythm Society, catheter ablation of atrial fibrillation in this patient would be recommended, AF catheter ablation is useful for symptomatic paroxysmal AF refractory or intolerant to at least one class I or III antiarrhythmic medication when a rhythm-control strategy is desired. In this patients case, the provider reported that the patient has symptomatic paroxysmal AF despite antiarrhythmic drug therapy. Thus, catheter ablation of atrial fibrillation was offered. In sum, the requested surgery to treat her heart rhythm is likely to be more effective than the standard options available for the treatment of this patients medical condition. Therefore, for the reasons stated 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 


A 63-year-old female enrollee has requested reimbursement and prospective authorization and coverage for physical therapy provided from 8/17/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient had post-operative disability after foot surgery and physical therapy was prescribed to improve function. The patient made improvement in physical therapy through 8/19/15. On that date further physical therapy was reasonable and medically necessary because the patient had continued deficits that are generally amenable to the care of a skilled physical therapist. Based on improvement up to 8/19/15, further improvement could be expected with skilled services. However, the patient did not show further improvement. As such, six additional physical therapy sessions after 8/19/15 were sufficient to show a plateau. After these six sessions, the patient could have been managed with a home exercise program. For the reasons provided, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Summary Reviewer 



A 54-year-old male enrollee has requested authorization and coverage for apremilast (Otezla) 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthritis. The physician reviewer found that the documentation provided do not support the medical necessity for the requested medication in this clinical setting. While the records indicate that this patient has failed two treatments with NSAIDs, the records do not demonstrate that he has tried and failed nonpharmacological treatments (ultravioletlight therapy), disease-modifying antirheumatic drugs (DMARD) therapies, or anti-tumor necrosis factor (TNF) agents. There is also no documentation that he has tried the standard topical therapy to address the psoriasis that covers at least ten percent of his body surface area. While apremilast may represent a promising therapy for the treatment of psoriatic arthritis and psoriasis, the medication should be tried after failure of other standard forms of therapy. Per Zerilli, and Ocheretyaner, Additional long-term studies are needed to further elucidate its place in therapy. As such, the requested medication is not medically indicated for the treatment of this patient. Therefore, for the reasons stated above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1

A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or class 2 based on the risk of metastasis. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 11/07/17 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 1


A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.  The physician reviewer found that the PET scan performed on 2/3/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. PET is a standard procedure performed by providers when dementia is atypical, and most specifically to differentiate Alzheimers disease from frontotemporal dementia. This diagnostic procedure allows the patient and his family to better understand prognosis and treatment, and guide the treating provider to provide the best treatment. In this case, MRI showed nonspecific atrophy. The EEG showed spike and slow wave discharges suggesting epilepsy. In addition, neuropsychology testing suggested frontotemporal dementia, and the examination showed Parkinsonian features. The patient presented with a subacute onset of progressive memory problems. In this complex clinical setting, the diagnostic procedure at issue was 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 diagnostic procedure 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 2


A 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria The physician reviewer found the clinical utility of LHR is not well established and there are currently no national Allergy and Immunology or Dermatology guidelines recommending routine use of this test. LHR is a test that consists of basophil histamine release assay.  This assay is used to detect anti-Fc-epsilon-RI-alpha antibodies. Some concerns with LHR is that there is evidence against a pathogenic role of autoantibodies to IgE or Fc-epsilon-RI and they are not specific to CU.  Anti-Fc-epsilon-RI-alpha antibodies have been identified in healthy normal people and those with other autoimmune diseases.  The level of these antibodies do not appear to change with the clinical disease activity. The presence of these antibodies do not appear to predict refractory disease. In this patients case, her symptoms are consistent with chronic idiopathic urticaria. Her evaluation to include LHR have all been negative.  As such, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to have been more effective than current standard therapy for evaluation of this patient. Therefore, for the reasons stated 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 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 9/01/16 was likely to have been more effective 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.