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

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for physical therapy services provided from 7/27/15 through 12/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees comminuted right patella fracture and shoulder pain.   The physician reviewer found that physical therapy services provided from 7/27/15 through 12/8/15 were not medically necessary for treatment of this patients medical condition. The documentation does not indicate that the patients deficits prevented her from independently forming an effective and appropriate home exercise program. The patient had extensive prior physical therapy and was educated in a home exercise program. There is no documentation of functional deficits that would improve significantly under supervised therapy beyond that expected with an independent home exercise program. The providers office notes indicate that on 6/1/15 and 6/30/15 her right shoulder range of motion and strength were unchanged and she had full right shoulder rotator cuff strength with some external rotation deficits. Her gait was much improved on 7/14/15 and her functional limitations were not of the complexity that they required continued supervised therapy. On 7/23/15 she was noted to be able to go upstairs without a handrail. Given these notes, the patients therapeutic benefit prior to 7/27/15 was met and any continued deficits did not require the supervision of the provider as her needs could have been met independently at home. Thus, the physical therapy services provided from 7/27/15 through 12/8/15 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 73-year-old male requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.  The physician reviewer found that the patient is a 73-year-old male status post heart and kidney transplant, diagnosed with recurrent squamous cell carcinoma of the skin of the scalp. He apparently had prior squamous cell carcinoma of scalp treated with radiation and Mohs surgery. In July 2016, he had recurrent cancer on his scalp, proven by biopsy. His tissue was sent for FoundationOne assay. The patient requested reimbursement for genetic testing performed on 9/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational.FoundationOne is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the FoundationOne assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment (Von Hoff, et al). A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment (LeTourneau, et al). Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the FoundationOne test provided on 9/26/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 

Based upon the information set forth above, the 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 45-year-old female with a family history of breast cancer in her mother. The patient 
presented on 12/16/22 for magnetic resonance imaging (MRI) of the breast as a screening for 
suspected malignant neoplasm of the breast. The Health Insurer has denied the services at issue as 
not medically necessary for the evaluation of the patients medical condition. This denial is the 
subject of this appeal and determination. The physician reviewer found that according to American 
College of Radiology (ACR) guidelines, annual breast MRI screening is indicated for high-risk 
patients with a lifetime risk of breast cancer of 20% or greater. The records available for review 
indicate that this patient has a family history of breast cancer and was calculated to have above a 
20% lifetime risk of breast cancer. The patient appropriately underwent a breast MRI to screen for 
suspected malignant neoplasm of the breast. Given these findings, the breast MRI performed on 
12/16/22 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested authorization and coverage for Sovaldi and ribavirin. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 2b.  The physician reviewer found that due to the approval and availability of new therapies, clinical guidelines and accepted standards of care were completely revised in late 2014. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C genotype 2, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Sovaldi and ribavirin are medically necessary for treatment of this patients medical condition. Consistent with these findings, the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 36-year-old female enrollee has requested authorization and coverage for intravenous immunoglobulin therapy. The Health Insurer has denied this request indicating that the requested therapy 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 therapy.  While there are a variety of criteria for common variable immunodeficiency, virtually all of these require significant reduction in levels of IgG, typically to values of 400 mg/dL or less.  Additionally, criteria also require impaired response to immunizations and documentation of severe and frequent sinopulmonary infection.  This patient does not have a low total level of IgG.  The subclass values are of unknown significance, but not generally considered clinically important.  Response to pneumococcal immunization here may be slightly reduced, but does not meet usual criteria for impaired response.  Documentation of severe recurrent sinopulmonary infection is not present.  The patient has had symptoms of facial fullness but a normal sinus CT.  All told, the requested intravenous immunoglobulin therapy is not medically indicated for the treatment of this patient.  Therefore, the requested therapy is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 52-year-old female enrollee has requested authorization and coverage for sclerotherapy. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found that review of the submitted documentation and relevant literature fails to support the requested services in this clinical setting. With respect to the right leg, the documentation does not support the proposed treatment. The patient reports on multiple occasions that the issue is with her left leg. Her symptoms are mild on the right leg. With respect to the left leg, sclerotherapy is not indicated given the lack of evidence demonstrating that the truncal reflux has been corrected and in the absence of truncal reflux, the patients activity limiting symptoms persist. For the reasons provided, the requested services are not likely to be more beneficial for treatment of this patients medical condition than the 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 62-year-old male enrollee has requested authorization and coverage for proton beam therapy. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  service  is 
investigational for the treatment of the enrollees prostate cancer. The physician reviewer found 
that in this clinical setting, the only justified use for proton therapy would be in a clinical trial. 
Standard radiation therapy for prostate cancer is with x-ray IMRT radiation therapy, which has 
been shown to carry no long-term significant side effects. There is a lack of evidence in current 
medical literature showing improvement in terms of local control of the prostate cancer or for a 
survival benefit with the use of proton therapy. The NCCN guidelines note that photon or proton 
EBRT are both effective at achieving highly conformal radiotherapy with acceptable and similar 
biochemical control and long-term side effect profiles. Takeda and colleagues reported a very 
low  rate  of  grade  3  urine  toxicity,  which  is  not  life-threatening  and  does  not  require 
hospitalization, in patients with prostate cancer treated with IMRT and no in stances of grade 4 
toxicity. In a study regarding 15-year outcomes data for 301 patients with prostate cancer treated 
with x-ray IMRT, Weg and colleagues observed grade 3 gastrointestinal toxicity in three patients 
and no instances of grade 4 toxicity. The Radiation Therapy Oncology Group (RTOG) protocol 
notes that the small bowel can tolerate a maximum dose of 50 Gy, which is more than the typical 
dosage of 45 Gy in 2 gray equivalent dosage for EBRT treatment of elective lymph nodes for 
prostate cancer. In this case, the patient reported concern regarding the potential impact of ADT 
due to his history of hypogonadism. In this clinical setting, the NCCN recommends brachytherapy 
and EBRT, noting that ADT is only optional in this setting. Therefore, proton beam therapy is not 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old male enrollee has requested authorization and coverage for acute rehabilitation inpatient services. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees status post left-sided hemilaminectomies, facetectomy, and discectomy at L2-3. The physician reviewer found the review of the submitted documentation and relevant literature demonstrated the medical necessity for the requested services. According to the documentation submitted for review, the patient has acute neurological deficits with impaired functional mobility and self-care. The patient is willing and able to participate in physical and occupational therapies. In addition, the patient requires the close medical supervision of a rehabilitation physician to monitor the acute neurologic deficits and adjust treatment accordingly. For the reasons provided, acute rehabilitation inpatient services are medically necessary for treatment of the patients medical condition. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 45-year-old male enrollee has requested authorization and coverage for Xanax. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees generalized anxiety disorder. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Generally, generic medications vary in bioavailability versus the name brand by no more than 15%.  In this case, the suggestion that the three generics the patient tried were not as effective suggests that the dose was not tailored properly.  The standard practice is to tailor the dose of the generic medication properly prior to prescribing a brand drug. This would be the first appropriate step in drug prescription and evaluation of efficacy.  In this patients case, the use of the brand name Xanax is not medically indicated. 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 Reviewer  
The patient is a 17-year-old female with no significant medical or surgical history. The patients 
parent has requested reimbursement for emergency room physician services (CPT 99285) 
provided on 4/10/21. The physician reviewer found that in this case, the patient presented with 
severe abdominal pain, and underwent an interview to obtain history, a physical examination, 
imaging with both ultrasound and CT scan of the abdomen and pelvis, and laboratory testing 
(including blood count, chemistry, and gastrointestinal pathogen panel). The findings and plan 
were discussed with her primary care physician. The finding of colitis with differential of 
inflammatory bowel disease and infectious colitis constituted a high-risk finding (with threat to 
life or bodily function) given the possible complications of bowel perforation, toxic megacolon, 
sepsis, inflammatory bowel disease flare, peritonitis, hemolytic uremic syndrome, abscess, 
fistula, or other complications. For these reasons (number of problems, data reviewed, and risk 
level), the code of 99285 is supported. Therefore, emergency room physician services (CPT 
99285) provided on 4/10/21 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment center services from 11/17/16 through 12/10/16. 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 that there is sufficient support in the records for the medical necessity of the services at issue in this clinical setting.  Evidence-based assessments are indispensable in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The medical literature states that children should be treated in the setting that is least restrictive and disruptive to their lives. More restrictive facilities, like inpatient or residential treatment, are indicated in emergencies or when patients are not responding to efforts at outpatient treatment. In this patients case, her psychosis had not resolved despite a medical hospital stay, followed by almost three weeks of psychiatric hospital stay and a weeklong PHP stay. The records indicate that this patient had failed the PHP directly prior to her RTC admission. The American Academy of Child and Adolescent Psychiatry recommends that children and adolescents be treated in the least restrictive setting possible to maintain and foster natural supports. This patient did not appear to have adequate treatment progress, and it would not have been safe to treat the patient in a less restrictive setting. The RTC was likely the least restrictive safe setting for this patient after having failed the PHP. Therefore, the mental health residential treatment center services from 11/17/16 through 12/10/16 were medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 38-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 10/16/18 through 10/25/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary level of care for adults. In terms of risk of harm, the records support a score of 1. There is a lack of documentation to support any current or recent suicidal ideation. In terms of functional status, the records support a score of 3. The records noted recent conflicted and withdrawn relationships with a lack of aggression. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no serious psychiatric symptoms. In terms of level of stress of the recovery environment, the records support a score of 3. The documentation noted a stable living environment at home, but significant discord with his spouse. With regards to level of support of the recovery environment, the records support a score of 2. The patient had a stressful relationship with his spouse, but he was going to work with her in therapy. In terms of treatment and recovery history, the records support a score of 3. The patient had shown progress in treatment and expressed motivation to remain sober. It is unclear if he has maintained significant sobriety in the past. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and apparent insight into need for treatment. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient treatment. The medical evidence indicates that intensive outpatient program treatment is effective for substance use. Thus, substance use residential treatment provided from 10/16/18 through 10/25/18 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 61-year-old female who has been diagnosed with attention deficit hyperactivity disorder (ADHD), malabsorption syndrome, and history of binge eating disorder. She is status post Roux-en-Y gastric bypass. On 2/2/17, the patient reported that Vyvanse lasts for four hours, there are no side effects, and the patients sleep is good. She finds taking it three times a day is effective. The provider indicated that she has been stable on this dose since 9/3/12, and needs this to continue as she works 12-14 hours a day. The Vyvanse 70 mg three times a day maintains her focus, concentration, and energy, and helps control erratic eating. The patient has requested authorization and coverage for Vyvanse 70 mg three times a day (TID). The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational. 
The records indicate that this patient has a history of ADHD, history of binge eating disorder, and is status post Roux-en-Y gastric bypass with malabsorption syndrome. As noted in the medical literature, malabsorption syndromes can occur in all gastric bypass procedures and can require patients to take higher doses than normal to achieve the desired effect. This patient has reported no side effects with continued efficacy. For these reasons, Vyvanse 70 mg TID is 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 medication dosage is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 40-year-old female with abnormal uterine bleeding thought to be secondary to her known uterine fibroids. The patient has requested authorization and coverage for laparoscopy, surgical ablation of uterine fibroids including intraoperative ultrasound guidance and monitoring radiofrequency. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the requested procedure is a minimally invasive radiofrequency ablation treatment that reduces fibroid-related symptoms by reducing fibroid volume. The procedure is performed through a laparoscopic approach. Alternative standard therapy to the procedure includes more aggressive interventions, such as hysterectomy or myomectomy. Interventional radiology embolization procedures are only successful in a certain patient population with fibroids in specific locations. The procedure is done as an outpatient basis, with return to normal activity within approximately one week. Using ultrasound guidance to identify the fibroid, a conductive needle array punctures the fibroid and transmits radiofrequency energy, which causes coagulative necrosis. An ultrasound probe is used to monitor the tissue effect until the bulk of the fibroid is treated. Over subsequent months, fibroids are reabsorbed with a decrease in fibroid volume and a resultant reduction in fibroid-related symptoms. This is directed therapy and allows for treatment in the proper candidate within a minimally invasive surgical approach. There is sufficient support for the requested services in this clinical setting. Therefore, laparoscopy, surgical ablation of uterine fibroids including intraoperative ultrasound guidance and monitoring radiofrequency is medically necessary for the treatment of this patient.