Persius/imr-appeals huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested authorization and coverage for uvulopalatopharyngoplasty for obstructive sleep apnea.  The Health Insurer has denied this request indicating that the requested services are 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 services.  This patient has mild obstructive sleep apnea and snoring.  It is noted that his obstructive sleep apnea is severe when in the supine position.  There is no documentation of retropalatal obstruction or of redundant palatal soft tissue.  While uvulopalatopharyngoplasty is a common surgical procedure for treatment of obstructive sleep apnea, its success rate as a stand-alone surgery is low.  Its success rate in conjunction with nasal surgery is not much greater.  The fact that apnea-hypopnea index is greater when in the supine position does not determine that there is retropalatal airway obstruction.  All told, the requested uvulopalatopharyngoplasty is not medically indicated for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 50-year-old male enrollee has requested reimbursement for BCR/ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that a patient may exhibit resistance to therapy, and mutational analysis may be needed. This is particularly important for those that have progressed on standard regimens. The medical evidence supports clinical trials for such patients and considers such referrals standard care. Von Hoff and colleagues performed a study of 86 patients. The progression-free survival on the regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The Tempus XT gene panel is a mutational analysis of tissue which includes IDH1/2, BCR-ABL1, BRAF, CEBPA and microsatellite instability test. This patient had mutational analysis performed on his meningioma, and some targeted regimens were recommended based on this tumor mutational analysis. The results from molecular profiling may offer a rational selection of the next regimen. Thus, BCR-ABL gene rearrangement and the Tempus XT Gene Panel Testing performed on 12/17/18 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 1

A 64-year-old male enrollee has requested reimbursement for the LifeVest provided from 3/31/17 forward. The Health Insurer has denied this request indicating that the device at issue was and is considered investigational for treatment of the enrollees myocardial infarction and congestive heart failure.   The physician reviewer found that LifeVest use is not recommended when the patient does not meet the criteria for an implantable cardioverter defibrillator (ICD). This patients occurrence of an infarct was within 40 days. In addition, once a coronary intervention such as a stent placement is performed, there is a 90 day waiting period during which medical therapy is maximized, in an effort to improve EF to 35% or greater. Overall, the pertinent literature does not demonstrate an improvement of health outcomes when a wearable cardioverter-defibrillator is deployed in the 90 day period post coronary intervention in the setting of a newly diagnosed ischemic cardiomyopathy. Therefore, the LifeVest provided from 3/31/17 forward was not and is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was not and is 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a 15-year-old male enrollee has requested reimbursement for Afirma gene testing provided on 6/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found thyroid nodules are commonly managed by diagnostic fine needle aspiration to evaluate the cytopathology. In this case the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present and but only subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted for gene expression analysis. The Afirma gene expression test has demonstrated a very high negative predictive value for malignancy (Alexander, et al; Chudova, et al). In this case, the Afirma test performed was clinically indicated and 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for Duavee 0.45-20 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post hysterectomy. The physician reviewer found that in this patients case, her menopausal symptoms included occasional hot flashes and vaginal dryness. There is no mention of other management options, including whether the patient has tried any other medicinal (hormonal or non-hormonal) and nonmedicinal forms of therapy and what the response to that therapy was, other than a prescription for Duavee. The benefit of Duavee is that it is selectively designed and marketed as a hormone replacement therapy that is more protective of the endometrium of the uterus than other progestins that are coupled with estrogens. This is not an issue for this patient. As she is status post hysterectomy, this patient does not need protection of her uterine endometrium. In this case, there are other reasonable estrogen only treatment options that would be more prudent for this patient. If the risks associated with estrogens and their potential relationship to breast/reproductive cancers is driving management, then the use of non-hormonal management, such as Paxil, may be a better option. The medical evidence does not support the requested medication in this patients case. Thus, Duavee 0.45-20 mg tablets are not medically necessary 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 49-year-old male enrollee has requested authorization and coverage for Crestor 20 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who was assessed with combined familial hyperlipidemia and Stevens-Johnson syndrome. The physician reviewer found that based on the records provided this patient has a history of Stevens-Johnson syndrome and he is tolerant of brand name Crestor. Medical evidence supports that in this circumstance, it would be reasonable and should be safe to transition the patient to generic rosuvastatin. Medical reviews of Stevens-Johnson syndrome associate the condition with active ingredients of certain medications. However, there is a lack of evidence to show that Stevens-Johnson syndrome is associated with any inactive ingredients that may be present in the generic medication but not present in the brand medication, Crestor. In this patients case, the submitted documentation does not show that this patient is intolerant to the generic rosuvastatin. In addition, generic medications, by law, must be bioequivalent with respect to efficacy when compared to brand medication. Based on the documentation provided and the medical literature, Crestor is not 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 59-year-old female who presented to her provider on 5/20/22 with newly diagnosed 
non-small cell lung cancer (NSCLC). The patient has requested reimbursement for chemotherapy 
treatment from 6/2/22 through 1/26/23. 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 the submitted 
documentation supports the medical necessity of the services at issue. The treatment of advanced 
NSCLC may involve either targeted therapy or a combination of a platinum-based cytotoxic 
chemotherapy along with pembrolizumab. In a trial of patients with metastatic NSCLC, without 
targetable mutations and without prior treatment, Gadgeel and colleagues reported that first-line 
pembrolizumab  plus  pemetrexed-platinum  significantly  improved  overall  survival  and 
progression-free survival  compared  with  placebo plus  pemetrexed-platinum in  patients  with 
metastatic nonsquamous nonsmall-cell lung cancer. In this case, the combination used was 
standard therapy and completely different from the atezolizumab/bevacizumab combination tried 
initially. The National Comprehensive Cancer Network (NCCN) guidelines on the treatment of 
NSCLC strongly support the chemotherapy that was used in this clinical setting. Therefore, 
chemotherapy treatment from 6/2/22 through 1/26/23 was medically necessary for the treatment 
of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 56-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845). The Health Insurer has denied this request indicating that requested procedure is considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that in this patients case, there is a lack of evidence that laparoscopic sleeve gastrectomy has failed or that duodenal switch will cure diabetes. She has been on Januvia and continues to lose weight. There is some evidence of noncompliance in diet and supplements. There is no direct intervention of stress eating and noncompliance with dietary and supplement restrictions. Moreover, there is a lack of documentation of whether her glycemic control has worsened in the last three years. The patients hemoglobin A1C is always documented as 7.2. This patient has not exhausted standard interventions for treatment of her diabetes. The patient would benefit from a full metabolic panel as well as dietary and psychiatric reevaluations. As such, the requested coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) is not likely to be more effective than standard options available for treatment of this patient.
Based upon the information set forth above, the requested procedure is 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 15-year-old male enrollee has requested reimbursement for Afirma gene testing provided on 6/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found the review of the submitted documentation and relevant literature supports the testing at issue in this clinical setting. This patient presented with atypical cells in the first biopsy.  It was important to clarify his risk of harboring a malignancy when the second biopsy came back indeterminate again. Molecular testing has been proposed as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. According to the American Thyroid Association (ATA) guidelines For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case the repeat biopsy was again indeterminate. Therefore the submission of the specimen to Afirma gene expression classifier was appropriate. The result was suspicious which indicates that the risk of malignancy was 40%. A benign result would have prevented unnecessary surgery in this young patient. The rate of unnecessary surgeries has decreased with the use of molecular testing (Alexander, et al). In this case the decision to refer the biopsy specimen to Afirma testing was appropriate for the best care of this patient. Based on the support in the peer-reviewed literature, the Afirma gene testing provided on 6/16/15 was likely to be more beneficial for evaluation of the patients medical condition than other modalities. Based upon the information set forth above, the testing 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 48-year-old male enrollee has requested reimbursement for substance abuse intensive outpatient program (IOP) treatment provided from 7/26/16 through 8/19/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found according to the documentation submitted for review the patient presented with a history of alcohol dependence. At the time of admission, he denied cravings, post-acute withdrawal symptoms, or risk to himself or others. He was medically and psychiatrically stable. The patient did not present with emotional, behavioral, or cognitive issues that would require treatment at the IOP level of care. He had demonstrated the capability of making behavioral changes after 6/22/16 by seeking help and attending AA, having a sponsor, and remaining sober. He was highly engaged in the program, and on admission had insight into his behavior and recognized his triggers. He has a long history of AA attendance, as such he is aware of relapse prevention. He had his support systems in place. He did not require the structure of an IOP setting. His substance abuse treatment and relapse prevention could have been performed at the outpatient level of care. All told, the IOP treatment provided from 7/26/16 through 8/19/16 was not medically necessary for treatment of the patients medical condition.Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 37-year-old male who presented to his provider on 2/22/22. The patient has 
requested reimbursement for anesthesia provided on 3/14/22. The physician reviewer found 
that the submitted documentation supports the medical necessity of the service at issue. Current 
medical  literature  supports  the  use  of  sedation  to  facilitate  gastrointestinal  endoscopic 
procedures such as colonoscopy. The two main options for sedation in the United States are 
either  traditional  moderate  sedation,  with  an  intravenous  benzodiazepine  and  opioid,  or 
propofol-based. A growing number of hospitals, ambulatory care centers, and other endoscopy 
sites  are  moving  toward  propofol-based  sedation  for  endoscopic  procedures.  Wang  and 
colleagues report, Propofol is safe and effective for gastrointestinal endoscopy procedures and 
is associated with shorter recovery and discharge periods, higher post-anesthesia recovery 
scores, better sedation, and greater patient cooperation than traditional sedation, without an 
increase  in  cardiopulmonary  complications.  The  American  Society  for  Gastrointestinal 
Endoscopy (ASGE) suggests the use of propofol-based sedation when it is expected to improve 
patient  safety,  comfort,  procedural  efficiency,  and/or  successful  procedure  completion. 
Generally, the endoscopist determines whether sedation will be propofol-based or a traditional 
moderate sedation. Secondary to the individual factors in this case, the anesthesia provided on 
3/14/22 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 59-year-old male with a diagnosis of benign prostatic hyperplasia (BPH) with 
lower urinary tract symptoms (LUTS) and atrial fibrillation. The provider has recommended a 
prostatic artery embolization (PAE) to treat the patients medical condition. The Health Insurer 
has denied this request and reported that the services at issue are not medically necessary for the 
treatment of this patient. This denial is the subject of this appeal and determination. The physician 
reviewer found that according to the European Association of Urology (EAU), management for 
BPH  includes  medical  treatments,  such  as  alpha  blockers,  5  alpha  reductase  inhibitors, 
phosphodiesterase inhibitors and anticholinergic medication (Grazke, et al.). For patients with 
BPH who do not respond to medical therapy, the recommended treatment is transurethral resection 
of the prostate (TURP). The EAU guidelines state that in patients with highly enlarged prostates, 
such  as  this  patient,  a  holmium  laser  enucleation  of  the  prostate  (HoLEP)  procedure  or 
prostatectomy would be also effective treatment for BPH. Current medical literature is limited for 
the effectiveness of PAE over procedures such as HoLEP, TURP or prostatectomy. The American 
Urological Association (AUA) guidelines on BPH, state that PAE is not recommended for the 
treatment of LUTS attributed to BPH outside the context of a clinical trial (Foster, et al.). Given 
this patients BPH with enlarged prostate and LUTS, the appropriate treatment would be HoLEP, 
TURP or prostatectomy based on the medical literature. Therefore, the requested PAE is not 
medically necessary for treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested authorization and coverage for a Cochlear Baha Attract System.  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 the requested services are not likely to be more effective for this patient than other available options. The Cochlear Baha Attract Hearing device has been adapted from its predecessor. Instead of having a bone-anchored external device requiring cleaning and maintenance, the Attract device is magnetically attracted to a surgically implanted magnet integrated into the bone of the skull. The external sound processor picks up sound vibrations from the environment. The sound processor passes the sound vibrations to the attached external magnet that attracts to the internal magnet. The sound vibrations are transferred through the magnetic attachment to the small titanium implant inserted in the bone behind the ear. The sound vibrations are then sent directly through the bone to the inner ear (cochlea) where they are converted into electrical impulses by tiny hair cells inside the cochlea. These impulses travel to the brain, allowing the patient to perceive sound naturally. The current medical evidence for the use of this device is limited to several small investigational reports. Iseri and colleagues reported on 12 patients and suggested the implant is promising and comparable to the percutaneous systems. Briggs and colleagues reported on 27 patients for up to nine months and stated improvement in speech understanding, but the investigation was not validated by others.  It is for the lack of other statistical evidence that this type of device has not been established as superior compared to standard treatments. The newest reports confirm evidence that the magnetic systems do provide excellent results to improve the hearing of patients with single-sided deafness. All told, the requested is 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 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.