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

Summary Reviewer 

A 62-year-old male enrollee has requested reimbursement for ICU level of care provided on 7/15/18 and intermediate level of care provided from 7/16/18 through 7/20/18. 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 this patient's ICU admission on 7/15/18 was medically necessary. Specifically, this patient had a left neck blood vessel exploration with muscle flap. The standard of care for this procedure is ICU admission postoperatively due to the high risk for airway compromise related to neck swelling or hematoma after exploration and flap coverage. Failure to treat could result in loss of the airway with acute respiratory failure and need for mechanical ventilation. As such, the ICU level of care was medically necessary and appropriate postoperatively for the first 24 hours after surgery. After the initial 24 hours following surgery, the patient was noted to be clinically stable, with a viable flap and no evidence of airway compromise. In this setting, admission to the intermediate care floor was clinically appropriate and consistent with the standard of care due to need for frequent flap monitoring. Furthermore, this patient had an unstable medical comorbidity of acute postoperative atrial fibrillation that occurred after surgery. Due to the acuity of the patient, with need for frequent monitoring, nasoenteric tube care and atrial fibrillation monitoring, the intermediate level of care was medically indicated. In sum, the ICU level of care provided on 7/15/18 and intermediate level of care provided from 7/16/18 through 7/20/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a three-year-old male enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program provided from 10/31/15 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 autism spectrum disorder with severe behavioral disturbance. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Swiezy and colleagues state Ultimately, training specific to autism spectrum disorders and related evidence-based practices is proposed as necessary for all care providers having influence on programming related to this special population. It is also posited that the most effective avenue for training is through models incorporating more intensive and interactive training processes such as hands-on learning activities with opportunities for coaching, modeling, practice and feedback. Effective collaboration across systems (including home, medical, educational, and community settings) is emphasized to facilitate consistency in implementation of strategies for ultimate program success. In this case, the patient has tried a lower level of care which was not effective as documented by multiple providers. As of 10/30/15 the patient has still not met his targets/goals and termination of treatment at this stage would be detrimental to patients short-term as well long-term prognosis. The patient is three years old and the medical literature shows that the best outcomes are associated with early intensive intervention. Based on the support in the peer-reviewed literature and the severity of the patients behaviors, partial hospitalization program provided from 10/31/15 forward was and is medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found the provider reports that the patient has been stable for the extensive period of time of seven years on a regimen of Adderall XR 60 mg in the morning and 30 mg in the afternoon. The patient is noted to have no side effects and is sleeping well. This supports the efficacy of the requested medication at a daily dose of 90 mg. Therefore, the requested brand Adderall XR 90 mg daily 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: Upheld

Summary Reviewer 


A 59-year-old female enrollee has requested authorization and coverage for Orthovisc injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthrosis. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.  There is also risk of iatrogenic infection being introduced into the joint during the process of injection.  Rutjes and colleagues performed a recent meta-analysis of the efficacy of viscosupplementation.  The study reviewed a total of 89 trials involving 12,667 adults and concluded that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk of serious adverse effects.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested Orthovisc injections are not medically necessary for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 51-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. 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 this patient has a medial talar dome osteochondral lesion with a large underlying bony cyst, and she has failed conservative management. Most studies looking at autologous chondrocyte implantation have been performed in the knee. Wasiak and colleagues concluded that while the use of autologous cartilage implantation and other chondral resurfacing techniques has become increasingly widespread, there is a lack of evidence of significant outcome differences between autologous cartilage implantation and other interventions. Currently, this procedure is not approved by the U.S. Food and Drug Administration (FDA) for use outside of the knee. At this time, the FDA has not approved the use of this technology in the ankle. Therefore, autologous chondrocyte implantation is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. 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 the patient is a 45-year-old female who was apparently asymptomatic with respect to her breasts. She has a family history of breast cancer (sister at age 40). On 2/6/15, she underwent a routine screening mammogram as well as a three-dimensional tomosynthesis examination.  Those studies were compared to prior mammograms dated 8/14/09, 8/6/10 and 9/23/11.  On the current examination, no abnormalities were detected, and there had been no interval changes. There were no masses, suspicious calcifications, or areas of asymmetry. Her breasts were described as extremely dense. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational. Tomosynthesis is a technique that was developed 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 the dense breast tissue. In this case, the patient has extremely dense breasts. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the above, the breast tomosynthesis performed on 2/6/15 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is an eight-year-old female who has been diagnosed with autism spectrum disorder.  The patients parent has requested reimbursement and prospective authorization and coverage for applied behavior analysis provided from 2/01/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. The physician reviewer found that the Council of Autism Service Providers (CASP) autism treatment guidelines include critical features of a treatment plan for service authorization. These guidelines include, but are not limited to, patient information, assessment information, treatment plan, caregiver training, transition and discharge plan, and hours requested. Per the records, these elements were present in this patients case. The goals identified were related to the patients diagnosis of autism (i.e., socialization, communication, stereotypy, self-monitoring, etc.). The authorization request also included baseline data on goals and several graphs detailing progress. Additionally, the requested services meet the medical necessity criteria outlined by Papatola and Lustig. Their definition includes health-care services that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are: (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care. The requested services meet the criteria outlined above. Specifically, the provider has identified how the services will meet the patients essential health needs. Applied behavior analysis is the most evidence-based treatment for autism, and the intensity of services requested is appropriate in this clinical setting. Therefore, applied behavior analysis provided from 2/01/20 forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 48-year-old female who presented to her provider on 10/5/22. The patient has 
requested authorization and coverage for a Humira 40/0.4 mL pen. The Health Insurer has denied 
this request and reported that the requested medication is not medically necessary for the 
treatment of this patient. The physician reviewer found that the submitted documentation does 
not support the medical necessity of the requested medication. Dactylitis, or inflammation of the 
whole digit, may respond to NSAIDs and some traditional, nonbiologic DMARDs such as 15 to 25 
mg once weekly dosing of methotrexate. Biologic DMARDs may be indicated, at times, in certain 
cases. In patients with enthesitis, improvements in dactylitis are reported as secondary outcomes 
in current medical literature regarding these agents. In this case, given that the records do not 
document a failure of, or contraindication to, traditional DMARDs, and as the patient has other 
manifestations of psoriatic arthritis besides dactylitis, the requested medication is not medically 
indicated. Therefore, Humira 40/0.4 mL pen is not medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 64-year-old male with attention deficit/hyperactivity disorder (ADHD) and intermittent explosive disorder. The patient was most recently prescribed divalproex for mood stability and Vyvanse for ADHD. The medical record made no mention of substance use disorder and did not detail the past psychiatric history or outcome of prior medications tried and failed. It appears that the patient was prescribed mixed-amphetamine salts for his ADHD, but experienced excessive perspiration, which prompted the prescription of Vyvanse in July 2017.  On 8/14/17, the records noted that the medication was well-tolerated and efficacious, and the hyperhidrosis resolved. The patient has requested coverage for Vyvanse 30 mg capsules. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  Stimulant medication is the gold standard pharmacologic intervention for ADHD.  Vyvanse is a central nervous system stimulant that was approved by the United States Food and Drug Administration in 2007 for the treatment of ADHD. The compound is a prodrug of dextroamphetamine. After oral administration, Vyvanse is rapidly absorbed and converted to dextroamphetamine, which is responsible for the drugs activity. Amphetamines generate a clinical effect by inhibiting norepinephrine and dopamine reuptake into the presynaptic neuron and increasing release of these monoamines into the extraneuronal space of the prefrontal cortex. In this patients case, the medical records do not substantiate the medical necessity of Vyvanse. Considering that amphetamines are associated with greater potency and mood lability when compared to methylphenidate-based products, and both classes are indicated for the treatment of ADHD, it would reasonable, safe and appropriate to trial long-acting methylphenidate. Considering this patients comorbidity, the Health Insurers alternative methylphenidate may be a better clinical fit. All told, Vyvanse 30 mg capsules are not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing 
performed on 1/11/21. 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 proper evaluation of adenocarcinoma of the lung requires assay 
for multiple specific mutations. This is performed on the tissue biopsy. Per the records, this was 
done on her initial biopsy specimen of 2017. It is also noted that she had a multi-genomic 
Foundation One assay in 2018. It is not clear why a further genomic assay, Guardant 360 testing 
was needed, in view of the other assays. Additionally, there is a note at the office visit of 
2/02/21 that indicated that the recurrent tumor was found to be EGFR mutation positive. It is 
not clear where this assay was performed, but it could have been done on the surgical 
specimen from the neck dissection. Although liquid biopsies can be used when it is not safe or 
easy to get tissue, this is not the case here. Tissue was available from the neck dissection.  Therefore, Guardant 360 testing performed on 1/11/21 was not likely to have been more 
beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 51-year-old female enrollee has requested authorization and coverage for Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%) eye drops. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees eye condition The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient has significant dry eye and chronic allergic conjunctivitis. Per the provider and noted by the patient, she has tried several of the over the counter medications without success or improvement of her symptoms. This patient has also been prescribed Pataday drops but those eye drops were also ineffective. The records indicate that this patient has tried and failed standard treatments. All told, Pazeo (olopatadine hydrochloride ophthalmic solution 0.7%) eye drops for treatment of this patients eye condition is medically necessary. Therefore, based on the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 32-year-old female enrollee has requested reimbursement for the laboratory testing provided on 6/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees miscarriage. The physician reviewer found that this patient had two very early pregnancy losses, and underwent an extensive work-up with multiple blood tests including a number of inherited thrombophilias. According to the American College of Obstetricians and Gynecologists (ACOG) guidelines on inherited thrombophilias a definitive causal link cannot be made between inherited thrombophilias and adverse pregnancy outcomes. The ACOG further noted that prospective cohort studies have found no association between inherited thrombophilias and fetal loss. All told, there is a lack of peer-reviewed medical literature or published guidelines to demonstrate that the laboratory testing provided on 6/6/16 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 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: Experimental
Decision: Upheld

Summary Reviewer 3 
A 49-year-old female enrollee has requested reimbursement for laboratory services performed 
at Diagnostic Solutions Laboratory on 3/29/22. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollee. The 
physician reviewer found that with gastrointestinal mapping continued to be studied, multiple 
studies are emerging to show the importance of microbiota in the diagnosis and treatment of 
disease process such as infection and malignancy. Ahluwalia and colleagues note, Patients with 
irritable bowel syndrome have a distinct faecal microbiota and metabolite profile linked to bowel 
habits. Intestinal microenvironment profiling, based on fecal microbiota and metabolites, may 
be considered as a future non-invasive diagnostic tool, alongside providing valuable insights into 
the pathophysiology of irritable bowel syndrome. Vasapolli and colleagues note that distinct 
fecal microbiota profiles are reported to be associated with various subtypes of irritable bowel 
syndrome. Gingras and Maggiore reported that the GI-MAP assay displayed a sensitivity of 80%. 
Buss and colleagues reported that gastrointestinal mapping panels showed high sensitivity and 
specificity in detecting gastrointestinal infections. Lam and colleagues report regarding mapping 
the microbial communities in the gastrointestinal tract that disturbances in these communities 
have been associated with GI cancers and that an interplay between microbes in carcinogenesis 
seems conceivable, especially in colorectal cancer. In this case, notes dated 3/18/22 reported 
that the patient had multiple gastrointestinal symptoms and a history of iron deficiency anemia 
and breast cancer. She had undergone laboratory testing and an invasive colonoscopy and 
continued to present a diagnostic challenge. In this case, given the patients diagnostic challenge, 
unresolving symptoms, and history of malignancy and iron deficiency anemia, gastrointestinal 
mapping was likely to have been more beneficial than standard diagnostic testing, particularly 
since the number of microorganisms tested with the service at issue were not all commercially 
available.  Therefore,  laboratory  services  performed  at  Diagnostic  Solutions  Laboratory  on 
3/29/22 were likely to have been more beneficial for evaluation of the patients condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. 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 there is a lack of support for the requested services in this clinical setting. This patient has a history of chronic lower back pain refractory to conservative treatment. There is a paucity of clinical trials supporting this procedure. There is a need for more clinical randomized, double-blind, placebo trials. The procedure is relatively new and has not been proven to make a difference or benefit in enough clinical trials. Thus, destruction of intraosseous basivertebral nerve is not likely to be more beneficial than any available standard therapy.