Persius/imr-appeals huggingface dataset:
Reviewer # 3:

This is a female patient who has successfully undergone 2 frozen embryo transfers. She is planning another attempt for in vitro fertilization pregnancy. She would like to have pre- implantation diagnosis for fetal aneuploidy using polar body biopsy.

The test is recommended for the member in expert guidelines and is the most appropriate test in these circumstances, and is shown to improve the rate of success for pregnancies in these circumstances and it also helps prevent pregnancies with aneuploidy. 
 
According to Vitez, S. F., et al. (2019), "Miscarriage is a frequent outcome seen in obstetrics with 1 in 5 pregnancies ending in an early pregnancy loss.  Aneuploidy is the most significant single factor affecting early pregnancy failure and miscarriage.  The risk of aneuploidy increases significantly with increasing maternal age.  There has been tremendous advancement in technology that has made preimplantation genetic testing for aneuploidy reliable and accessible.  For women in their mid-to-late 30s there is great utility in the use of PGT-A to facilitate single embryo transfer, reduce the risk of clinical miscarriage and ongoing aneuploidy gestations.  The current data supports use of preimplantation genetic testing for aneuploidy and single embryo transfer for this population of women."

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed, as this procedure is likely to be more beneficial than any of the standard testing / procedures.
Reviewer # 2:
This is a female patient, gravida 3 para 1. She has twins who were previously conceived with in vitro fertilization of cryo preserved embryos from her original in vitro fertilization cycle with oocyte polar body pre-implantation genetic testing for aneuploidy.

According to Capalbo, A., et al. (2016) states, "Blastocyst biopsy is now widely used for both preimplantation genetic screening (PGS) for aneuploidies and preimplantation genetic diagnosis (PGD) of single gene defects.  In particular, trophectoderm biopsy coupled with comprehensive chromosome screening (CCS) now represents the most promising approach for PGS to detect aneuploidies coming from both male and female meiosis, as well as clinically relevant mitotic errors fixed during preimplantation embryo development."      

The patient is a good candidate for this procedure because she is at increased risk of conceiving embryos with fetal aneuploidy due to her history of infertility and advanced maternal age.     

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be reversed.
Diagnosis: IVF with preimplantation genetic screening. 
 
Treatment: 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos.  

The insurer denied the 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos. The denial was reversed. 

Reviewer #1: 

This is a female patient G3P1 who previously received in vitro fertilization. She has a history of frozen embryo transfer twice without success. Her last attempt of frozen embryo transfer resulted in a biochemical pregnancy.  She would like to attempt another in vitro fertilization cycle with preimplantation genetic screening.
American Society of Reproductive Medicine (ASRM) also stated the following:" A study of women with recurrent miscarriages found no evidence of benefit of preimplantation genetic screening in women of any age."

At this time there are no data to support preimplantation genetic screening for recurrent unexplained miscarriage and recurrent implantation failures; its use for these indications should be restricted to research studies with appropriate informed consent. 

This patient is not a good candidate for the procedure, as the scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome.

89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos does not have final approval from the appropriate regulatory bodies for this diagnosis.
The requested service is not the best available treatment for this patient at this time, and is not likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of coverage 89290 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos and 89291 Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos should be upheld.
Diagnosis: Back pain
Issue under review: Intracept procedure

Determination:
The health plan should not cover the intracept procedure.

The health plan should not cover the proposed treatment based on general standard of care for vertebrogenic pain, and based on the patient not meeting the following recommended requirements by RELIEVANT, the Intracept Medical device manufacturer (source: https://www.relievant.com/wp-content/uploads/2019/05/MKT_0066-RevD_-_Reimbursement_Guide.pdf):

 Intracept is medically indicated in patients who have
- A history of low back pain of at least 6 months duration; and
- Failed to respond to at least 6 months of non-surgical management; and - MRI demonstrated Modic Type 1 or Type 2 changes* at one or more vertebrae from L3 to S1; and
- Activities of daily living that are limited by persistent low back pain; and 
- All other reasonable sources of pain have been ruled out.

The above-recommended requirements have not been met for the INTRACEPT procedure, because despite history of chronic low back pain of more than six months, the MRI findings did not point to any evidence of Modic type 1 or type 2  changes at any vertebra. There is also no documented evidence of limitation of ADLs (activities of daily living) by the patient, and that all other reasonable sources of the chronic low back pain have been ruled out.
Diagnosis: Back pain
Issue under review: Intracept Procedure

Determination:
The health plan should cover the Intracept procedure.

Although intraosseus radiofrequency treatment of the basivertebral nerve (Intracept procedure) is a relatively new treatment for low back pain with Modic endplate changes, there is adequate evidence from randomized controlled trials, cited below, including a multi-center trial, to substantiate its effectiveness.  The patient's symptoms and the MRI evidence of Modic endplate changes confirm that the patient suffers from the type of back pain that has been shown to benefit from this treatment.
Diagnosis: Back pain
Issue under review: Intracept procedure

Determination:
The health plan should cover the Intracept procedure.

The requested procedure is a new, albeit FDA-approved procedure with this patient's indication in mind. There are RCT (randomized controlled trials) that show its effectiveness at two years.  In fact, there is another follow-up study where it was recommended that patients cross over to the treatment arm due to effectiveness early on.  The indication is for back pain that is thought to be originating from endplate degeneration (modic changes), which is what is shown in this patient. The patient has failed conventional treatment, including PT (physical therapy), Medial branch blocks, and medications. 

Given that the alternative options (lumbar fusion), have not shown to have favorable responses for axial low back pain in the literature and is much more invasive, the requested Intracept procedure should be approved.
This patient has a past medical history of atrial fibrillation, multiple myeloma, deep venous thrombosis and recently had surgery for a leg fracture. The patients physician submitted a letter in support of increasing home care hours from 7 hours per day, 7 days per week to 10 hours per day, 7 days per week, and includes the following: Over the past year, the patient has had multiple hospitalizations and admissions for rehabilitation. 
 
The insurer denied coverage for personal care aide (PCA) services 10 hours per day, 7 days per week (total 70 hours per week). The denial was reversed.

This patient has extensive health problems and functional impairments.  She lives in a private home with her son and is dependent on assistance from others for all instrumental activities of daily living (IADLs) and needs extensive to maximal assistance for all activities of daily living (ADLs), except eating (limited assistance).  Based on her medical history, it appears the patients functional limitations are associated with various medical conditions, e.g. heart failure (may cause dyspnea, fatigue); arthritis (pain, decreased range of motion, unsteady gait); multiple myeloma (back pain, fatigue); obesity, body mass index (BMI 34.2; obesity is associated with risk for progression of osteoarthritis, and increased functional limitations and disability in the elderly). In addition, the patient needs assistance for locomotion/walking, transfers, toileting, incontinence care which occur at various and unscheduled times during the day and night.  The level of assistance needed by the patient for most ADLs requires substantial physical assistance from the caregiver (weight-bearing support).  Even when the patient is in bed, she needs extensive assistance for bed mobility.  This is an important aspect of her care, as immobility increases risk of pressure ulcers, so she needs help repositioning when in bed. The patient cannot prepare her meals; and she needs some assistance with eating.  Therefore, the patient would not be able to effectively manage having a meal, snack or fluids when she is alone. As per New York State regulations for personal care services, assistance from informal caregivers is voluntary.  The patients son is the only informal caregiver identified in the 2019 Uniform Assessment System. The patient needs a caregiver (paid or voluntary) present in her home to provide assistance with ADLs (including toileting, incontinence care, transfers, locomotion, bed mobility) during the day and night as a result of her functional impairments associated with multiple medical conditions. The son is requesting PCA services 10 hours per day (3 more hours per day than currently approved).  It is reasonable to conclude that he cannot provide care on a consistent basis for 10 hours per day. Therefore, it is medically necessary for PCA services to provide the assistance the patient requires during those 10 hours.
The patient presented to the ER with a 3 day history of nausea, vomiting, and diarrhea and was subsequently admitted to inpatient.  The health plan has denied the inpatient stay as not medically necessary.  The health plan's determination is overturned.  This patient with nausea, vomiting, and diarrhea had moderate dehydration based on both clinical and laboratory evaluation and failed prior outpatient and ED management.  She required overnight hospitalization for continued IVF hydration to ensure safe discharge.
The patient has a past medical history significant for hypertension, gastroesophageal reflux disease, cataract, hypercholesterolemia, anxiety disorder and polyarthritis. She requests personal care service hours. These services were denied as not medically necessary. The health plan's determination is upheld. The personal care hours are not medically necessary. The patient can perform many of the tasks independently - at least 50% of the task. She is able to ambulate, toilet, and eat independently. There are no noted additional services that were noted to be medically necessary.
Diagnosis: Prostate Cancer
 
Treatment: Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815)

The insurer denied the Positron Emission Tomography (PET) Scan Skull Base to Mid-Thigh (78815). The denial was upheld. 

This is a male patient with a medical history of hypertension, hyperlipidemia, coronary artery disease (CAD), a myocardial infarction (MI); status post cardiac stent, renal colic with stent placement, prostate cancer status post prostatectomy. Due to the patient's rising PSA of 0.06 several years ago to 0.32 in early 2019, a positron emission tomography (PET) Flucicovine Axumin scan was performed. The test revealed no evidence of metastatic disease or local reoccurrence.  

Axumin PET scans were FDA approved in 2016 for biochemical recurrence of prostate cancer, namely a rising PSA noted after definitive local therapy, such as radical prostatectomy or radiation therapy. FDA approval of Axumin included a trial showing it to perform as well, if not better, than C11 Choline scans in patients with median PSA value of 1.44. The optimal utilization of Axumin PET scans has yet to be fully delineated by NCCN or American Urological Association (AUA) guidelines. NCCN also notes it is unclear what to do when such imaging is positive in setting of negative conventional imaging. However, imaging with this modality is felt to be most useful early in the course of a suspected biochemical recurrence.  

The patient's PSA had shown an increase over several years. In any event, in the setting of BCR (biochemical recurrence) for previously treated prostate cancer, CT scan and bone scan remain first line imaging, despite their limitations in limited volume disease recurrence. As noted, the role of Axumin PET remains unclear. In this case, in fact, the patient had radiation therapy after the negative PET Scan. This is consistent with the lack of clarity of how this test affects therapy in setting of suspected recurrence.  

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.

The carrier's denial of coverage for the Positron Emission Tomography (PET) scan skull base to mid-thigh (78815) performed is upheld. The medical necessity is not substantiated.
Diagnosis:  Substance abuse
Treatment:  Inpatient rehabilitation
The inpatient rehabilitation substance use disorder treatment was not medically necessary for this patient.

The patient presented with substance use disorders, diagnosed with alcohol and stimulant/cocaine use.  He self-referred and received inpatient level rehabilitation treatment.  He readily engaged in treatment and had no biomedical or psychiatric treatment issues.  During the time interval under review, the patient was noted to be in no apparent distress with reasonable functioning and active participation in treatment including positive interactions with staff and peers.  Throughout his inpatient stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care, structure or 24-hour monitoring.  The application of NY State OASAS LOCADTR 3.0 Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting, as the health plan asserts.  Thus, medical necessity for the inpatient rehabilitation substance use disorder treatment is not met in this case scenario, also consistent with ASAM Criteria, the scientific literature and published guidelines, referenced below.

The patient in this case scenario is not clinically appropriate for an inpatient level of care during the time interval under review.  The patient had presented with a level of stability and no co-occurring psychiatric disorders or safety concerns that would have warranted inpatient level care.  He did not need 24-hour monitoring or the structure of an inpatient setting in order to receive effective substance use disorder treatment.  He readily engaged with treatment and was involved with peer supported recovery groups that could have been provided in a less restrictive treatment setting with sober supports or living.  Thus, the health plan's determination is reasonable in this case scenario.  This answer is consistent with prevailing standards of medical practice for the conditions diagnosed and under treatment in this case, and consistent with the application of NY State OASAS LOCADTR 3.0 Guidelines.
Abdominal pain
Inpatient hospital

The patient is a female with medical history of gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and colitis treated with antibiotics 2 months prior. She presented to the emergency department with left lower quadrant abdominal pain, nausea, vomiting, and diarrhea with scant red blood since the night before, as well as weakness and a feeling of dehydration. Vital signs were unremarkable. Physical examination was notable for tenderness in the left lower quadrant of the abdomen. She was admitted to the hospital.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient had abdominal pain, nausea, and diarrhea consistent with acute gastroenteritis or colitis. Computed tomography scan of the abdomen and pelvis showed enteritis and possible colitis but was not consistent with pathology such as gastrointestinal perforation, pancreatitis, abscess, toxic megacolon, or bowel obstruction. Although uncomplicated gastroenteritis and/or colitis may have been present, the patient did not have peritonitis, sepsis, ongoing gastrointestinal bleeding, or other complications warranting inpatient level of care. She was appropriately treated with intravenous fluids and antibiotics. The measures which were undertaken, such as observation, monitoring, labs, antibiotic administration, intravenous fluid administration, and sitter monitoring could have been performed at a lower level of care.
Diagnosis: Dental-deep impinging overbite
Treatment: Dental/Orthodontic Procedure

Summary: This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation Index Report (HLD) as required and has chosen the automatically qualifying condition of deep impinging overbite with signs of soft tissue damage.
 
The insurer has denied coverage for orthodontic treatment-service codes D8080 (braces) and D8670 (monthly visit x4) as not medically necessary. The denial was reversed.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the HLD Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.
Diagnosis: pain
Issue under review: inpatient admission

Determination:
Inpatient admission was not medically necessary.

The patient presented with lower abdominal pain off and on for three days, associated with vaginal discharge. On presentation in the ED, she was hemodynamically stable and afebrile, and her abdominal examination was remarkable for mild to moderate right lower quadrant tenderness with no signs of peritonitis. Her CBC, UA, CMP (comprehensive metabolic panel), and ABG were normal. The CT scan of the abdomen/pelvis and US pelvis were unremarkable except for appendicolith and small ovarian cyst. Her abdominal pain resolved with IV fluids and pain medication, and in the afternoon of 11/08/2018, her abdominal pain was better and she was able to tolerate diet. She slept well overnight and discharged home next day. Since she had no evidence of infection, dehydration bowel obstruction, peritonitis, and did not need any surgical or endoscopic intervention, and she felt better within 24 hours of hydration and pain management, she could have been safely managed at the lower level of care.
Diagnosis: Respiratory System (Asthma)
Treatment: Inpatient Hospital

Summary: This patient presented to the Emergency Department (ED) for asthma exacerbation. Oxygen saturations in the field were in the 80's. He was placed on oxygen and given intravenous (IV) steroids and magnesium. He also was treated with bronchodilators. He denied cough, fever, chills or chest pain. Past medical history included asthma, history of multiple intubations, hypertension and morbid obesity. Vital signs at triage were temperature 97.7, blood pressure 169/87 mm Hg, heart rate 79, and respiratory rate 20. Oxygen saturation was 100%. The patient was alert and oriented x 3 and in no apparent distress. There was no distension of the jugular vein. There was diffuse wheezing on auscultation. Abdomen was soft. He could move all extremities. White blood count was 11.5 and hemoglobin 11.8. Lactate was normal. Electrolytes were within normal limits. Brain natriuretic peptide was 29. Troponin was < 0.015. Urine toxicology was negative. Cannabinoids was positive. Arterial blood gases were 7.392/41/106. Oxygen saturation was 98%. Chest X Ray showed no infiltrates, effusions or pneumothorax.

The insurer has denied coverage for the inpatient hospital admission as not medically necessary. The denial was upheld.

As per the history and physical, vital signs were temperature 98.3F, blood pressure 177/89 mm Hg, heart rate 95, respiratory rate 16, oxygen saturation 98 % on room air. The patient was in no apparent distress. He was speaking in full sentences. No use of accessory muscles was noted. Lungs had a bilateral mild end expiratory wheeze. The patient's admission diagnoses were acute asthma exacerbation likely secondary to weather change and marijuana use. Based on review of the medical record, acute hospitalization was not medically necessary. The patient could have been placed in observation status. He was improving after treatment in ED. He was afebrile and hemodynamically stable as per history and physical. He was not hypoxic. Chest x-ray showed no infiltrate. This patient could have been treated with IV steroids, bronchodilators and inhaled corticosteroid combination inhalers and long acting beta agonist inhalers while under observation. The patient remained stable overnight and was discharged the next day. He could have been placed on observation status while diagnostic testing and treatment was initiated.