Persius/imr-appeals huggingface dataset:
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient presents with a personal history of breast cancer diagnosed at a young age as well as a first-degree relative diagnosed with breast cancer at a young age. She has already been tested and found to be negative for BRCA1 and BRCA2. Given the young age of breast cancer diagnosis in both the patient and her mother a strong likelihood of an inherited mutation exists. Panel testing helps guide management of the patient in screening for additional cancers that may be more likely if an inherited mutation is found. Therefore, the molecular pathology testing provided on 4/14/16 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: Overturned

Summary Reviewer 2

A 30-year-old male enrollee has requested reimbursement for immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19. 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 at the time of presentation to the hematologist, the patients complete blood count was normal, and the thrombocytopenia and leukopenia noted during his acute illness in 2018 were resolved. Thus, the records do not support a suspected a lymphoproliferative neoplastic process in this patient, or a screen for such a process using this molecular tool. Gene arrangement assays in T-cells and B-cells are appropriate in situations where a morphological or immunophenotypically aberrant population of lymphocytes have been identified, typically either in peripheral blood, in an enlarged lymph node, or in the bone marrow, and where there is a need to clarify whether this population of cells is clonal. In this case, none of these conditions applied. Flow cytometry of peripheral blood was normal. The providers assertion that repeat complete blood count continued to reveal evidence of significant cytopenias is not supported by the test results from January 2019. Screening for a lymphocytic leukemia using gene rearrangement assays on peripheral blood in this case was without utility. In sum, immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 33-year-old male enrollee has requested authorization and coverage for PET imaging with CT attenuation skull base to mid thigh. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that PET/CT has become the most important imaging modality to evaluate lymphoma. PET/CT plays a crucial role in staging, restaging, prognosis, planning treatment regimens, monitoring therapy, and detecting disease recurrence. Generally, clinical symptoms provide the earliest evidence of recurrence, and approximately 80% of patients with proven recurrence are symptomatic. In this case, the patient is currently symptomatic, with multifocal pain as well as generalized symptoms, such as fatigue. The patients disease is particularly aggressive, and he initially presented with an abdominal mass at the time of diagnosis. Therefore, in a patient with abdominal pain particularly, imaging is necessary to exclude disease recurrence. The most accurate imaging modality to assess for recurrence is PET/CT. Thus, PET with CT attenuation, skull base to mid-thigh, is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  They can lead to acute and chronic pain as well as increased mortality.  Prolia is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone.  Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy.  As this patient is at high risk for a fracture and has failed therapy with Fosamax, the Prolia injection performed on 8/27/15 was likely to have been more efficacious than other treatment options.  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: Experimental
Decision: Upheld

Summary Reviewer 1


A 50-year-old female has requested authorization and coverage for sacroiliac joint fusion.  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 the International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive sacroiliac joint fusion provides specific indications for surgery. Criteria include: significant sacroiliac joint pain or significant limitations in activities of daily living because of sacroiliac joint pain; sacroiliac joint pain confirmed by at least three positive sacroiliac joint provocative tests; confirmation of the sacroiliac joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular sacroiliac joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and sacroiliac joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled out. This patient presents with a long history of axial low back and bilateral sacroiliac joint pain which is reported as severely debilitating.  She has been diagnosed with sacroiliac arthropathy.  She reported a remote history of trauma.  Clinical examination findings are generally consistent with sacroiliac joint pathology with positive compression and distraction tests, but do not document three positive examination findings consistent with evidence-based medical guidelines.  There is a lack of imaging findings documented relative to the right sacroiliac joint that confirm sacroiliitis due to spondyloarthropathy.  Thus, the medical evidence does not support the requested services in this clinical setting.  Therefore, the requested sacroiliac joint fusion is not likely to be more effective than other treatment options.  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: Upheld

Summary Reviewer 

The patient is a 38-year-old male who has a history of idiopathic thrombocytopenic purpura and a pulmonary embolus in November 2018 for which he was on apixaban anticoagulation. The patient has requested authorization and coverage for the RT300 FES Therapy System. The Health Insurer has denied this request and reported that the requested equipment is not medically necessary for the treatment of this patient. The physician reviewer found that this patient had residual right-sided greater than left-sided weakness following multiple insults to the brain in mid-2019. He underwent extensive rehabilitation that included multidisciplinary therapies and made significant functional improvements. A functional electrical stimulation cycle ergometer was prescribed for home use. The functional electrical stimulation cycle ergometer that was prescribed for home use is not medically necessary for treatment of the patientas condition. The medical literature has not shown that the device improves neurological, functional or health outcomes in a clinically significant manner following stroke, whether ischemic or hemorrhagic, or whether cerebral or cerebellar. A recent meta-analysis by Ambrosini and colleagues did not find that functional electrical stimulation-induced cycling improved outcomes better than usual care for subacute stroke survivors. The use of this type of device is not an evidence-based component of stroke management, rehabilitation or prevention of complications following stroke as noted on multiple recent reviews. Therefore, the requested RT300 FES Therapy System is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
A 43-year-old male enrollee has requested reimbursement for injection(s), platelet rich plasma, 
any site, including image guidance, harvesting, and preparation when performed, on 3/7/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational 
for the treatment of the enrollees left elbow pain and bicipital tendinitis of the left shoulder. The 
physician reviewer found that while current medical literature supports the use of PRP injections 
for the treatment of lateral epicondylitis in specific patients, there are only very limited studies 
available regarding the use of PRP for the treatment of bicipital tendonitis. In a systemic review 
of PRP versus corticosteroids for the treatment of elbow epicondylitis, Li and colleagues found 
that after long-term follow-up at 24 weeks post treatment, PRP injections had improved pain and 
function more effectively than corticosteroid injections. In a systematic review of the efficacy of 
PRP on tendon and ligament healing, Chen and colleagues conclude, PRP may reduce pain 
associated with lateral epicondylitis and rotator cuff injuries. While evidence regarding the 
success of PRP therapy is not conclusive, the risks associated with it are minimal. In light of the 
foregoing, PRP injection for treatment of lateral epicondylitis and bicipital tendonitis can only be 
recommended in carefully selected cases where all other therapies have been tried and the 
options are limited. In this case, notes dated 3/7/22 reported that  the patient has G6PD 
deficiency. For such a patient, the risks of corticosteroid injections may outweigh the benefits, 
especially given that PRP injections carry minimal risks. A patient with G6PD deficiency has a risk 
for hemolytic anemia which can be triggered by certain medications. In this clinical setting, the 
benefits of PRP far outweigh the current standard treatment of with corticosteroids, as they are 
more effective in improving pain and function than corticosteroid injections, with reduced risk as 
there are minimal risks with PRP injections over corticosteroid injections. Therefore, injection(s),  PRP, any site, including image guidance, harvesting, and preparation when performed, on 3/7/22, 
was likely to have been more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 52-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the sinuses performed on 1/12/16.  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 fails to demonstrate the medical necessity of the services at issue.  The medical literature supports the use of CT scan in diagnosis and treatment planning in the setting of chronic recurrent rhinosinusitis.  However, it is not within standard of care to repeat a scan in this clinical setting.  There is no medical indication for this patient to have undergone a second CT one month after a prior scan showed lack of disease.  All told, the CT scan of the sinuses performed on 1/12/16 was not medically indicated in this particular situation.  Therefore, the services at issue were 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 23-year-old male with a lifelong history of nasal obstruction that was refractory to prolonged topical nasal steroid spray. In a letter dated 3/05/20, the provider noted that the patient was found to have a left septal deviation, bilateral inferior turbinate hypertrophy, and bilateral alar collapse with dynamic obstruction of the internal and external nasal valve with inspiration. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this clinical setting. The patient had nasal obstruction that was found to be due to septal deviation, turbinate hypertrophy, and alar collapse. He underwent a septoplasty, turbinate reduction, and alar batten grafts. Reconstruction of the nasal valve is essential in improving nasal breathing. Performing the septoplasty and turbinate reduction alone would not have improved the patientas breathing given the valve collapse was present. Therefore, CPT 30465 performed on 12/18/19 was medically necessary for the treatment of this patient.
The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function; (2) To create a normal appearance, to the extent possible. In this patientas case, the records support that an abnormal structure of the body. The
patient had weak cartilage on the sides of the nostrils. This abnormal structure of the body is likely congenital. The services at issue were performed in order to improve function. Therefore, CPT 30465 performed on 12/18/19 was reconstructive in nature.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 34-year-old male has requested authorization and coverage for multileaf collimator device. 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 per the submitted records, the Health Insurer has approved coverage for IMRT. However, the requested 77338 x 45 is not considered to be more beneficial than standard therapy. Per coding guidelines, 77338 represents the multileaf collimator device for intensity IMRT, design and construction per IMRT plan.  This code is to be billed only once per plan, regardless of the number of ports constructed for the plan. Therefore, superior efficacy of the requested services has not been established.  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 


The parent of a 15-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found the submitted documentation supports the medical necessity of the requested medication in this patients case. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; growth velocity less than the 25th percentile for bone age; bone age more than two standard deviations below the mean for age; low serum IGF-1 and/or IGFBP-3; and/or other clinical features suggestive of growth hormone deficiency. Although this patient meets only some of the above criteria, he has been receiving growth hormone therapy since May 2016, with improvement in growth velocity. It is difficult to discern in retrospect how much of the improvement of his growth velocity is due to growth hormone therapy versus endogenous sex steroid production with progression in puberty. However, withdrawal of growth hormone therapy at this point in time, during mid-puberty, is not medically appropriate and may significantly compromise final adult height. Therefore, continuation of growth hormone therapy is medically necessary until epiphyseal fusion. All told, Humatrope 24 mg cartridge is medically necessary for the treatment of this patient. Therefore, the requested medication is 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 reimbursement for the DecisionDx-Melanoma Assay provided on 12/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the standard protocol based on National Comprehensive Cancer Network (NCCN) guidelines for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Currently, the protocol includes wide local excision and sentinel node biopsy. The decision to pursue medical treatment is based on the results of these tests. There is a lack of clinical studies that show that the results of molecular testing results in improved patient health outcomes when compared to standard evaluation. All told, the DecisionDx-Melanoma Assay provided on 12/6/17 was not medically necessary for evaluation of this patients melanoma. Based on the foregoing discussion, the services at issue were 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 


A 19-year-old male enrollee has requested reimbursement for the substance abuse subacute residential treatment services provided from 7/11/15 through 8/8/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees substance abuse, anxiety, and depression. The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings optimize treatment gains and referrals to higher level of care ordinarily progress in a step-wise fashion. However, bypassing intermediate levels of care for episodic placement in more restrictive settings is often clinically appropriate for those with serious psychiatric disease and addictive illness. It is impossible for even the most comprehensive of standard placement algorithms to account for the myriad of variables unique to complex cases. Accordingly, we entrust physicians and therapists working directly with the patient population to interpret and apply clinical guidelines and patient placement criteria, in consideration of clinical presentation and treatment needs, to determine the appropriate level of care and length of stay. The American Psychiatric Association (APA) states that decisions regarding the site of care should be based on the patients ability to cooperate with and benefit from the treatment offered, refrain from illicit use of substances, and avoid high-risk behaviors as well as the patients need for structure and support or particular treatments that may be available only in certain settings. In this particular case, the patient was unable to maintain sobriety in his current environment. He was non-adherent with psychotropic medication and was cognitively impaired. He was demonstrating new onset psychotic symptoms that may have been secondary to drug use or the manifestation of a formal thought disorder. On 7/10/15, the patient was in total denial while his behaviors were described as angry, labile and paranoid. Based on the patients burgeoning psychosis, abysmal insight and lack of any significant progress in the outpatient setting, 24-hour substance abuse residential treatment program services were indicated. Further, the required level of supervision and treatment could not have been conducted at a less restrictive setting. Moreover, the residential program was recommended by a board certified psychiatrist following a failed attempt of outpatient treatment. All told, the substance abuse subacute residential treatment services provided from 7/11/15 through 8/8/15 were medically necessary for treatment of this patients medical condition. 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 


A 45-year-old male enrollee has requested authorization and coverage for modafinil 200 mg. 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 review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Based on the documentation provided for review, the patient presents with severe obstructive sleep apnea and has been appropriately treated for this condition with residual daytime sleepiness. Residual sleepiness in well-treated obstructive sleep apnea is a U.S. Food and Drug Administration (FDA) approved indication for modafinil. The medical literature demonstrates the efficacy of modafinil for this indication. Black and Hirshkowitz studied once daily modafinil or placebo in patients diagnosed with obstructive sleep apnea/hypopnea syndrome with residual excessive sleepiness during CPAP therapy. The authors concluded These results confirm previous shorter-term controlled trials, indicating modafinil is a useful adjunct therapy for improving wakefulness in patients with residual excessive sleepiness associated with obstructive sleep apnea/hypopnea syndrome who were treated with [nasal CPAP] nCPAP. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.