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

Summary Reviewer 




The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment provided from 6/16/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition The physician reviewer found that the residential treatment provided from 6/16/16 forward was not and is not medically necessary for treatment of the patients medical condition. Per the Child and Adolescent Level of Care Utilization System (CALOCUS), the patient qualifies for Level Four, intensive integrated services without 24-hour psychiatric monitoring. Specifically, this level of care would include placements such as group homes or foster care. This level qualifies him for treatment by a child psychiatrist and nurse as well as individual and family therapy. Support services should also be provided. Specifically, in Dimension I, risk of harm, he scores as some risk of harm. Dimension II, functional status, he qualifies as serious functional impairment. Dimension III, co-morbidity developmental, medical, substance use and psychiatric, he qualifies as major co-morbidity. In Dimension IV, recovery environment, he scores as minimally stressful environment as his material needs are met without significant cause for concern. He also has a highly supportive environment, as the documentation notes he has access to a private school, tutors, and therapists. In Dimension V, resiliency and treatment history, he has shown poor resiliency and poor response to treatment. In Dimension VI, treatment acceptance and engagement, he has shown an obstructive engagement, as he was ambivalent, avoidant or distrustful in his relationship with clinicians and other care providers. However, his parents showed an optimal acceptance and engagement in his treatment. Given the above, the RTC level of care as of 6/16/16 was not and is not medically necessary for treatment of the patients medical condition.Therefore, the services at issue were not and are 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 

A 28-year-old male enrollee has requested reimbursement for CPT code 29879 performed on 2/12/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient sustained a skiing injury to his left knee. The initial diagnosis on 1/23/19 was lateral meniscus tear and possible ACL graft laxity. Additionally, there was a possible chondral injury, loose body, and chondromalacia. On 2/12/19, the patient underwent surgery, which consisted of left knee arthroscopy, repair of anterior cruciate graft, partial medial and partial lateral meniscectomies, removal of multiple loose bodies, abrasion chondroplasty of the lateral femoral condyle, and peripheral nerve blocks. The operative report documents a large articular defect of the lateral femoral condyle treated by abrasion chondroplasty down to bleeding bone. The medical evidence supports abrasion chondroplasty in this clinical setting. Studies have revealed good results with both mechanical chondroplasty and radiofrequency chondroplasty upon follow-up for four years. Therefore, CPT code 29879 performed on 2/12/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement for intensity modulated radiation therapy provided from 12/01/16 through 1/13/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees rectal cancer. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Standard treatment for rectal cancer is with three-dimensional conformal techniques. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with intensity modulated radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the rectum.  Consensus group guidelines do not support the use of intensity modulated radiation therapy in this setting.  Also, a phase II study by Hong and colleagues which examined the use of intensity modulated radiation therapy in patients with rectal cancer found no benefit when compared to historical controls. The dose comparison was reviewed as well and shows no clinically significant benefit with the use of intensity modulated radiation therapy over standard three-dimensional techniques. All told, intensity modulated radiation therapy provided from 12/01/16 through 1/13/17 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: Upheld

Summary Reviewer 1


A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that according to the American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines, Pap-only strategies are now limited to women younger than 30 years, but co-testing is expanded even to women younger than 30 years in some circumstances. The American College of Obstetricians and Gynecologists (ACOG) noted that if screening with primary HPV testing is used, it should be performed as per the ASCCP guidance. According to this patients provider, the patient was at increased risk for abnormal Pap smears and thus increased risk for the changes that lead to cervical cancer. Thus, the HPV testing provided on 8/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested authorization and coverage for CPT 43284 (magnetic sphincter augmentation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the LINX Reflux Management System works by augmenting the lower esophageal sphincter with a ring of magnets. Eligible patients must demonstrate typical gastroesophageal reflux disease symptoms, an abnormal pH study, at least partial response to daily proton pump inhibitor (PPI) therapy, and absence of a large hiatal hernia or severe esophagitis. This patient meets all of these criteria. Warren and colleagues performed a manometric study of 121 patients before and after the procedure. LINX was associated with an overall increase in the median lower esophageal sphincter resting pressure, residual pressure, and distal esophageal contraction amplitude. Sixty-seven percent of patients with a manometrically defective lower esophageal sphincter were restored to a normal sphincter with LINX. Seventy-seven and 56 percent of those with a structurally defective or severely defective lower esophageal sphincter improved to a normal lower esophageal sphincter. Only 18 percent of patients with a normal preoperative manometric lower esophageal sphincter deteriorated after the procedure. In the study by Ganz and colleagues, the long-term safety and efficacy of the LINX prosthesis was evaluated in a prospective single-group trial of 100 patients with long-standing gastroesophageal reflux disease. Gastroesophageal reflux disease-related quality of life was better. No device erosions, migrations, or malfunctions occurred. There is support for the requested services in this clinical setting. Therefore, CPT 43284 (magnetic sphincter augmentation) is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this case, the patients presenting symptom was breast pain.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In addition, her breast density was described as containing scattered areas of fibroglandular elements.  Her breasts were not particularly dense.  Breast tomosynthesis has not been shown to provide significant increased value in this clinical setting.  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  
The patient is a 73-year-old male who presented to his provider on 5/11/23. The records noted that 
the patient initially presented with an elevated prostate-specific antigen of 6.5 ng/mL in 2019. The 
patient has requested authorization and coverage for PBRT. The Health Insurer has denied this 
request and reported that the requested service is 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 does not support the medical necessity of the requested service 
Proton beam has unique properties compared to standard photon or x-ray beam in its ability to 
deposit radiation doses. The use of proton beams potentially results in fewer areas of low scattered 
radiation dose as fewer proton beams may be used to achieve a dose distribution similar to standard 
photon beams. Proton therapy is currently utilized and strongly indicated in settings where severe 
toxicities would result if normal tissue constraints cannot be met by photon beam. However, in the 
setting of localized prostate cancer, there has not been a demonstrable clinically significant 
improvement in either quality of life or reduction of high-grade toxicities. Studies in current 
medical literature have not demonstrated a significant difference in overall survival nor normal 
tissue toxicities over photon beam in the treatment of prostate cancer. These data question the 
utility of proton beam radiation particularly for patients with localized disease. There are ongoing 
prospective trials investigating the potential benefits in disease outcomes and toxicities, however, 
no definite benefit has been demonstrated for proton beam at this time. While proton therapy may 
be medically indicated in some cases of unusual anatomy or in cases of re-irradiation of adjacent 
tissues, this is not the case for this particular patient. In this clinical setting, given this patients 
medical history and the nature of his prostate cancer diagnosis, the requested service is not 
medically indicated. Therefore, PBRT is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 42-year-old male enrollee has requested authorization and coverage for an implanted neurostimulator pulse generator system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS) considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP therapy. This patients clinical examination shows the tonsils present with elongation and redundancy of the soft palate. This was documented on the drug induced sleep endoscopy with the recommendation that the patient consider mandibular advancement procedures. Although the patient meets certain clinical criteria for implantation of a hypoglossal nerve stimulator with a body mass index (BMI) of less than 32 and positive evaluation by drug induced sleep endoscopy, the patient has not been offered other potential surgical options such as uvulopalatopharyngoplasty (UPPP) and the clinical status of the patients results of additional CPAP titrations studies are unknown. Overall, other procedures are likely to provide this patient with improvement in symptoms beyond that expected with hypoglossal nerve stimulation. Thus, the requested implanted neurostimulator pulse generator system 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 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 2

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that botox is considered within the standard of care for patients with chronic migraine. Botox has also been approved by the U.S. Food and Drug Administration (FDA) to treat chronic migraine. In the peer-reviewed medical literature, Dodick and colleagues concluded that Botox is an effective and well-tolerated prophylactic treatment in migraine patients with CDH [chronic daily headache] who are not using other prophylactic medications. This patient has reportedly tried and failed gabapentin, which is an anticonvulsant, as well as nortriptyline and duloxetine, which are antidepressants. The patient is noted to have chronic daily migraine with zero headache free days at baseline. Accordingly, the Botox injections (CPT code 64615) provided on 5/26/17, 8/25/17, and 11/17/17 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were 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 parent of a three-year-old female enrollee has requested reimbursement for speech therapy provided from 1/06/15 through 5/28/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  As noted by Nelson and colleagues, the identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age when chances for improvement are best.  Law and colleagues noted that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties.  This patient has moderate expressive language delay negatively impacting her ability to communicate effectively and express her wants and needs.  The literature supports the efficacy of speech and language therapy in this clinical setting.  All told, speech therapy provided from 1/06/15 through 5/28/15 was medically indicated for the treatment of this patient.  Therefore, 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: Overturned

Summary Reviewer 

The patient is a 43-year-old female who was admitted for treatment of alcohol use disorder on 7/22/19. The patient has a history of severe alcohol use disorder and had been drinking in a binge type fashion. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Society of Addiction Medicine (ASAM) criteria reviews the six dimensions of assessment to determine the appropriate level of care. In terms of dimension 1, acute intoxication and withdrawal potential, the patient was in mild alcohol withdrawal, with the possibility of Xanax withdrawal as an additional concern. She endorsed multiple symptoms of withdrawal, including agitation, insomnia, nausea, and restlessness. She was unable to cope with withdrawal discomfort. The CIWA was 9 on admission. Overall severity is rated as moderate. With regard to dimension 2, biomedical conditions, the patient was recently diagnosed with bronchitis/atypical pneumonia and was on oral antibiotics. She was having difficulty coping with her symptoms such that it was distracting from her recovery. Overall rating is moderate. In terms of dimension 3, emotional/behavioral/cognitive conditions and complications, she had a history of depression, anxiety, and undiagnosed eating disorder. She had sought treatment from her primary care provider and was prescribed Xanax, which complicated her anxiety and alcohol use disorder. She reported intense urges to use alcohol and was engaging in binge episodes for several days at a time. Thus, the overall severity is moderate. With regard to dimension 4, readiness to change, she voiced a desire to stop drinking but felt unable to refrain from drinking due to overwhelming urges to drink. She required structured therapy and 24-hour program milieu in order to stop. Therefore, the severity is moderate. In terms of dimension 5, relapse, continued use or continued problem potential, this patient was experiencing severe psychiatric distress that was contributing to cravings and urges to use alcohol. Thus, the severity is severe. With regard to dimension 6, recovery environment, the patients husband had an alcohol use disorder and had a recent relapse. Therefore, the severity is moderate. Based on the submitted documentation, the patient met criteria for subacute residential services. Thus, substance abuse sub-acute residential treatment center services provided from 7/29/19 through 8/18/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 31-year-old male with a history of chronic right knee pain with associated instability, locking, catching, popping, numbness, swelling, night pain, and pain with activities. The patient has requested authorization and coverage for autologous cultured chondrocytes implantation, knee. 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 this patient has severe knee pain due to a 2 cm x 2 cm focal chondral defect of the lateral patellar facet which has significantly impaired his quality of life. Matrix-induced autologous chondrocyte implantation is a procedure which cultivates the collagen membrane with harvested chondrocytes from a prior surgical procedure prior to implantation and is known to be highly successful for this indication. This patient has had a thorough physical examination and arthroscopic evaluation, and there is no question about the pain generator. The partial lateral meniscectomy was not effective in relieving his pain. Imaging studies were corroborated by the arthroscopic findings. Conservative management was tried prior to proceeding with arthroscopy. Chondral biopsies were obtained from the non-weight bearing zone of the articular surface of the femur. Based upon a review of the recent medical literature, this patient is an excellent candidate for the requested procedure. Therefore, the requested autologous cultured chondrocytes implantation, knee is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 51-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees lower leg pain. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. The standard of care criteria for MRI of the lower extremity is a six week trial of conservative treatment which may include rest, ice, compression and elevation (RICE), non-steroidal anti-inflammatory drugs (NSAIDs), narcotic and non-narcotic analgesic medication, oral or injectable corticosteroids, viscosupplementation injections, a physician directed home exercise program, cross-training, and/or physical therapy, or immobilization by splinting, casting or bracing. The clinical information submitted for review demonstrates that the patient has not met these criteria. There is no documentation of a physician supervised six week trial of conservative treatment. In sum, there is insufficient documentation of the required physical therapy participation or follow-up visits provided in the medical records. Based on the medical records submitted and the peer-reviewed literature, the requested MRI is not medically necessary for evaluation of the patients medical condition. For the reasons provided, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 20-year-old female who presented to her provider on 3/2/21 with chronic sacral 
and coccygeal pain for the past seven months. The patient has requested reimbursement for MRI 
CPT 72195 on 12/29/21. The Health Insurer has denied this request and reported that the service 
at issue was not medically necessary for the evaluation 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 service at issue. Current medical literature regarding the use 
of MRI for the evaluation of low back pain note that MRI may be indicated in some clinical 
presentations to rule out infectious or tumor processes. In this case, the patient had failed maximal 
conservative care and had ongoing severe pain and functional limitations. Given that this patient 
had failed six weeks of conservative care in a comprehensive manner, the use of MRI was 
supported to rule out infectious or neoplastic causes for the pain. Therefore, MRI CPT 72195 on 
12/29/21 was medically necessary for the evaluation of this patient.