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

Summary Reviewer 


A 54-year-old female enrollee has requested authorization and coverage for bilateral upper lid blepharoplasties with removal of excessive skin. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees bilateral functional ptosis. The physician reviewer found that in the medical literature, Cahill and colleagues noted that blepharoplasty indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment. An MRD-1 of 3 mm does not fulfill the current criteria for upper blepharoplasty regardless of the visual field interpretation and photographs provided for review. For these reasons, the requested bilateral upper lid blepharoplasties with removal of excessive skin is not supported as medically necessary for treatment of this patients excess skin. Based on the foregoing discussion, the requested service is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 57-year-old male with a history of obstructive sleep apnea and prior smoking.  A clinic note dated 5/15/17 documented longstanding but increasing frequency of rapid palpitations relieved with Valsalva maneuver including several episodes in the last year.  There is reference to ambulatory electrocardiographic monitoring that did not capture an arrhythmia. There is no documented history of syncope. A comprehensive invasive diagnostic electrophysiology study was performed on 9/20/17 and reported a dual atrioventricular nodal physiology but there was no inducible sustained dysrhythmia.  An implantable loop recorder was then inserted. The patient has requested reimbursement for implantable event recorder inserted on 9/20/17. The Health Insurer has denied this request and reported that the procedure at issue was investigational for the treatment of this patients medical condition. The patient has a history of increasing frequency of palpitations without syncope, occurring several times in the last year. In this circumstance, prolonged outpatient self-activated event recording should be sufficient in documenting heart rhythm during symptoms and is less invasive than an implantable event recorder. Moreover, there is less risk for infection when compared to placement of an implantable loop recorder. The medical studies do not recommend an implantable loop recorder as an initial test for heart rhythm monitoring in patients with occasional symptoms such as this patient.  Implantable loop recorders can be useful for patients with very infrequent symptoms that are potentially injurious (syncope, for example) or when searching for asymptomatic occult episodes of atrial fibrillation, such as following a cryptogenic stroke. As such, the implantable event recorder inserted on 9/20/17 was not likely to have been of greater benefit than the standard method of managing this patients medical condition. Based upon the information set forth above, the procedure at issue was 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 1

A 39-year-old male enrollee has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the LINX procedure is not likely to be more effective for this patient than other available treatment options. There is a lack of documentation provided that demonstrates the patient is not a candidate for a Nissen fundoplication, which is the gold standard surgical treatment for GERD. Based upon a prospective study by Lipham and colleagues of 44 patients who underwent placement of the LINX System most patients at up to four years of observation experienced improved quality of life and complete cessation of the use of proton pump inhibitors. However, the studies to date have not had a control arm and each patient is used as their own control. The durability of the procedure is also unknown. Although early studies in regards to LINX are encouraging, the studies to date are primarily less than five years. Because of the lack of controlled data and long-term studies, the requested LINX procedure 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented with persistent and function-limiting left hip pain following total hip arthroplasty in 2015. His pain interfered with activities of daily living. Clinical examination findings were consistent with iliopsoas tendonitis. He had failed long-term conservative treatment, including physical therapy, activity modification and medications. He underwent left hip arthroscopic surgery on 8/27/18 and was diagnosed with left hip iliopsoas tendinitis and anterior inferior iliac spine (AIIS) impingement. Surgery was performed to include left hip aspiration of synovial fluid for culture and sensitivity, left hip lysis of adhesions, iliopsoas lengthening, subspinal decompression, removal of ossified capsule, and left hip parallel capsulotomy and capsular closure. The current medical literature supports iliopsoas lengthening and subspinal decompression following failure of conservative treatment and prior to revision total hip arthroplasty. In sum, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested reimbursement for substance use inpatient detoxification/residential services provided from 10/19/15 through 11/20/15. 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 the documentation does not support the medical necessity for the services at issue. There were no emotional, behavioral, or cognitive symptoms to warrant residential level of care from 10/19/15 through 11/20/15. The patient was not in withdrawals. He showed no suicidality or homicidality.  He was medically and psychiatrically stable.  He had not used opioids for at least nine months prior to admission. Cocaine use disorder does not require inpatient treatment.  The records did not indicate that he was not placed on any new medications.  There was no evidence of a high degree of impulsivity, aggression, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was accepting the principles of treatment, had a strong background of 20 years of sobriety with a history of very active involvement in AA as a member, sponsor, and speaker.  Given this, he would have had some insight into the disease process of addiction.  He learned and implemented skills and worked on a relapse prevention plan.  He did not require the 24 hours a day, 7 days a week environment of residential. He could have been treated in intensive outpatient program. As such, substance use inpatient detoxification/residential services provided from 10/19/15 through 11/20/15 were not medically necessary for treatment of this patient. Therefore, for the reasons stated above, 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 2 
 
A 60-year-old female enrollee has requested authorization and coverage for percutaneous or 
endoscopic spinal surgery. 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 this patient has had prior posterior decompression and fusion. Her 
complaints of pain and fatigue are consistent with symptomatic spinal stenosis. The patient has 
failed multiple lumbar treatments. The articles cited below note that the endoscopic decompression 
planned is as effective as open decompression surgery for lumbar stenosis as seen on the patients 
CT  scan  of  3/31/21.  These  benefits  are  achieved  at  a  much  lower  risk  and  require  less 
hospitalization.  Therefore,  percutaneous  or  endoscopic  spinal  surgery  is  likely  to  be  more 
beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested authorization and coverage for Synvisc One injection. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that an exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Per the literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections and in carefully selected cases when everything else has been tried and the options are limited. In this case, there is a history of lasting benefit from viscosupplementation over the last several years. Furthermore, the patients options are limited. She has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Therefore, the requested Synvisc One injection is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 19-year-old female with short stature, congenital heart disease, multiple minor malformations, and borderline intellectual disability. A specific diagnosis could not be recognized.  Chromosomal microarray was performed to investigate the etiology of the patients medical issues, in order to direct the patients medical care more specifically. The patient has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement and reported the services at issue were investigational for the evaluation of the patients medical condition.  Array-based comparative genomic hybridization (CGH, or chromosomal microarray) has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies.  Formerly, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal; however, currently it is considered a first-line investigation.  The yield of this test is approximately 8 to 17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The cited references indicate that this test has become an important and mainstream tool in the practice of clinical genetics.  As early as 2007, its utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability.  More recently, its clinical utility has been confirmed in a study by Henderson and colleagues where 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management (including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation).  Medical literature has shown that microarray results affect clinical management, at rates, which are similar to other genetic testing. Given the potential to influence management, microarray is an appropriate test to perform in this clinical scenario. Accordingly, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been more effective for the evaluation of this patients medical condition than the other available modalities.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1
A 47-year-old male enrollee has requested authorization and coverage for endovenous vein ablation (CPT code 36478). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins. The physician reviewer found that the documentation does not support the superior efficacy of the requested services in this clinical setting.  The patient does not present with significant symptoms. His presentation was for a duplex and a request for additional elastic stockings, which he found helpful.  There is no documentation that his symptoms are affecting his daily activities. The patient specifically notes that his occupation does not require him to stand or sit for prolonged periods of time. His symptoms of tingling in the thigh are unlikely to be addressed by ablation of his greater saphenous vein below the knee. Due to the relationship with the saphenous nerve, he is at increased risk for nerve related symptoms (tingling) following the procedure.  Additionally, it is not possible to attribute any of this patients leg symptoms to his residual varicose veins without an assessment of lower extremity arterial perfusion in the form of a pulse examination or noninvasive study. Therefore, endovenous laser vein ablation (CPT code 36478) is not likely to be more effective than the standard options available for the treatment of this patients medical condition.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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine without contrast. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees bilateral upper extremity pain and numbness. The physician reviewer found that the American College of Radiology (ACR) criteria recommends a plain x-ray for evaluated of patients with chronic neck pain. The ACR criteria suggest that for patients with radiographic evidence of degenerative changes and positive neurologic symptoms, the most appropriate test is an MRI of the cervical spine. This patients numbness and diminished reflexes are considered neurologic signs. Although this patients records do not document conservative therapy in addition to chiropractic care, the provider noted concern that continuing chiropractic manipulation may cause further damage without properly ruling out a significant herniation or stenosis. For these reasons, the requested MRI of the cervical spine without contrast is medically necessary for evaluation of this patients chronic neck pain. Based on the foregoing discussion, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a deceased male enrollee has requested reimbursement for substance abuse intensive outpatient program services provided from 1/1/13 through 2/11/13. 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 the substance abuse intensive outpatient program services provided from 1/1/13 through 1/17/13 was medically necessary for treatment of the patients medical condition, but not thereafter. In this case, the patient was not suicidal or homicidal. He was not aggressive or violent towards others. He was medically and psychiatrically stable. By 1/18/13 he demonstrated improved energy, stamina, understanding, and communication skills. He was motivated as evidenced by his active participation in the program. His family was supportive and participated in his treatment plan. In addition, the services provided through 1/17/13 were indicated to develop and solidify the aforementioned skills towards use in the outpatient setting. Therefore, 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for Oxycontin. 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 that the submitted documentation fails to establish the medical necessity for the requested medication. According to Argoff and Silvershein A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. In this case, the patient has a long history of pain and has had a number of interventions with ketamine infusions, sympathetic blocks, and opioids. However, there is no notation of results of a prior urinary drug testing before the conversion to another opioid medication, especially since the prescribing provider has had limited interaction with this patient to establish a baseline.  All told, the medical necessity of the requested mediation has not been established in this clinical setting. Therefore, the requested medication 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 3


A 44-year-old female enrollee has requested reimbursement for Prometheus testing performed on 4/30/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found in this case, testing was ordered to determine the etiology for possible loss of response to Humira and to direct the management of the patients ulcerative colitis. The effectiveness of the testing at issue compared with conventional courses of action, for example change of dose or change of medication, remains unproven.  The published studies on the use of anti-adalimumab antibodies and serum levels are small and retrospective and/or observational in nature. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  For these reasons, there is not sufficient evidence to demonstrate the superior efficacy of the service at issue.  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: Upheld

Summary Reviewer 




A 41-year-old male enrollee has requested reimbursement for computed tomography (CT) of the head without contrast performed on 9/08/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees headaches. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The medical evidence does not support CT scan of the head in this clinical setting.  The American College of Radiology Appropriateness Criteria is divided into several categories.  The one most closely reflects this patients presentation involves chronic headache, no new features, and normal neurologic examination.  The American College of Radiology states, In adult and pediatric patients with migraine, but without recent change in attack pattern, history of seizures, or other focal neurologic symptoms or signs, the routine use of neuroimaging is usually unwarranted.  The yield of CT or magnetic resonance imaging (MRI) in patients with headache but normal neurologic examination is generally quite low.  Douglas and colleagues noted most patients presenting with uncomplicated, non-traumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits red flags or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause.  All told, CT of the head without contrast performed on 9/08/16 was not medically indicated for the evaluation of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.