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

Summary Reviewer 

This patient is a three-year-old female who was admitted to Presbyterian Hospital in Albuquerque, New Mexico on 7/15/18. While on vacation in New Mexico, she developed a fever. She was initially evaluated and diagnosed with a viral illness. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Non-emergency air ambulance transportation for inter-facility transfers is considered medically necessary when a patient is medically stable and requires a higher level of care or services that cannot be provided at the sending institution. In such cases, the patient is transferred to the closest facility capable of provided the needed services. In this case, the documentation supports that the patient was transferred from Presbyterian Hospital in Albuquerque, New Mexico to Ann and Robert H. Lurie Children Hospital in Chicago, Illinois in order to be closer to home. The patient was receiving appropriate care. Her condition was noted to be medically stable, and she was discharged home four days after her transfer. Therefore, air ambulance provided on 7/21/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity.   The physician reviewer found that the Health Insurer denied reimbursement for the services at issue. Per the Health Insurer, the services at issue were investigational for evaluation of this patients medical condition.
There is sufficient support in the medical literature for the efficacy of the services at issue in this patients case. The comparative genetic microarray is a deoxyribonucleic acid (DNA) test which studies a very small sampling of a patients DNA utilizing small snippets called single nuclear pleomorphisms (SNP). The test first came into clinical utilization around 2005, but subsequently has become a mainstream test for a variety of clinical conditions which are the result of genetic abnormalities. Current medical evidence supports the clinical utility of the services at issue to assist in the treatment and management of patients in this clinical setting.  Therefore, CMA testing (CPT code 81229) performed on 1/26/16 was likely to have been more effective than other forms of therapy for the evaluation of this patient.  Based upon the information set forth 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: Overturned

Summary Reviewer 3


A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. 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 that there is sufficient support for the services at issue in this patients case.  The initial biopsy report was suspicious for follicular neoplasm.  The genetic testing noted that the right nodule was suspicious.  This was a major determining factor in delineating the further course of action to see if a possible surgical procedure was warranted.  Afirma testing is considered standard protocol in this clinical setting.  There is sufficient literature to indicate that this test can be performed to avoid unnecessary surgeries.  Thus, Afirma Thyroid Fine Needle Aspiration Analysis gene testing was likely to have been of greater benefit than other method of evaluating this patient.  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: Upheld

Summary Reviewer 

The patient is a 35-year-old female with a diagnosis of rheumatoid arthritis. She has tried and failed Plaquenil, nonsteroidal anti-inflammatory drugs and steroids. The physician reviewer found that the tumor necrosis factor (TNF) inhibitors, such as Cimzia, are a recognized alternative to standard disease-modifying anti-rheumatic drug (DMARD) therapy for patients who fail first-line DMARD therapy, as was the case in this patient. Unfortunately, management of rheumatoid arthritis in pregnancy is fraught with difficult issues as most agents are toxic to developing embryos. The records indicate that the patient has tried and failed Plaquenil, nonsteroidal anti-inflammatory drugs and low dose steroids for the treatment of her rheumatoid arthritis. Additionally, she has not responded adequately to U.S. Food and Drug Administration (FDA) and manufacturer recommended dose of Cimzia. However, there are many other therapies she has not tried and failed. The requested therapy is twice the FDA and manufacturer recommeded doses for the treatment of her condition and has not been proven to be the most safe and effective treatment for this diagnosis. Cimzia is not approved for intended use at requested doses. The provider is concerned because the patient is attempting conception. Although Cimzia is pegolated and intheory does not cross the placenta, it is not recommended in pregnancy by the manufacturer. The medical evidence does not support the requested medication regimen in this clinical setting. Therefore, Cimzia 200 mg injection, four per month is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 56-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram (breast tomosynthesis) provided on 1/9/17. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer.  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. 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. For the reasons provided, the 3D mammogram (breast tomosynthesis) provided on 1/9/17 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 service 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 3


A 57-year-old male enrollee has requested authorization and coverage for the Inspire hypoglossal nerve stimulation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that CPAP is a first-line approach in treating OSA and has been proven to be effective with compliance. This patient has been documented to no longer be able to tolerate CPAP and the high pressures necessary to effectuate an adequate result. Traditional upper airway surgery targets the anatomic components of obstruction, but was not effective in this patient. Upper airway stimulation has been shown to improve anatomic and neuromuscular pathology in this clinical setting. A large multicenter, prospective trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. Because this patient with severe OSA has failed standard medical and surgical treatments, the requested Inspire hypoglossal nerve stimulation is likely to provide him with a superior health outcome when compared to standard available therapies. Based upon the information set forth above, I have determined the requested services are 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: Overturned

Summary Reviewer 3 
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational for 
the evaluation of cystic fibrosis of the enrollees fetus. The physician reviewer found that the ACOG 
recommends screening for cystic fibrosis carrier states in the general pregnancy population. While 
ACOG does not recommend complete analysis of the CFTR gene in routine screening, it should 
be noted this case does not represent a routine screening event. In this case, the patient had specific 
findings of echogenic bowel that required extended testing for less common variants of cystic 
fibrosis mutation. In this clinical setting, this testing is standard, the most accurate screening tool 
available, and allows for appropriate counseling and medical planning for the pregnancy for the 
best possible outcome. Therefore, genetic testing on 4/14/22 was likely to have been more 
beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 70-year-old male who was being treated for other spondylosis, lumbosacral 
region; other intervertebral disc displacement, lumbar region; spinal stenosis, lumbosacral 
region; other forms of scoliosis, lumbosacral region; and lumbar radiculopathy. The patient has 
requested authorization and coverage for spinal surgery (CPT codes 22612, 22853, 63044, 
22848, 63042, 22614, 22842, 22558, 63048, 22585, 63047, 22800 and two inpatient days). The 
physician reviewer found that Bydon and colleagues noted, A trial of conservative therapy may 
be considered for patients with low-grade spondylolisthesis presenting with radiculopathy 
and/or pseudoclaudication. These options may include physical therapy, epidural steroid 
injection, and pain medications. If unresolved, surgical options may include decompression 
alone or decompression and fusion. Chan and colleagues noted, Patients with symptomatic 
lumbar spondylolisthesis may first be treated with conservative management strategies 
including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid 
injections, transforaminal injections, and physical therapy. For well-selected patients who fail 
conservative management strategies, surgical management is appropriate. Resnick and 
colleagues noted, As a result of the decompression, the inherent instability associated with the 
spondylolisthesis may progress and lead to further misalignment that results in pain or 
recurrence of neurological complaints. Under these circumstances, lumbar fusion is considered 
appropriate to stabilize the spine and prevent delayed deterioration. This patient was being 
treated for other spondylosis, lumbosacral region; other intervertebral disc displacement, 
lumbar region; spinal stenosis, lumbosacral region; other forms of scoliosis, lumbosacral region; 
and lumbar radiculopathy. He presented with increased back pain. He has had intermittent loss 
of bowel and bladder control. He also has noticed some weakness, particularly in the left lower 
extremity. His pain has increased significantly. Examination reveals weakness in the left 
iliopsoas at 3+/5, left glut and hamstrings at 4/5. These are new findings since September 2021, 
when he was neurologically intact. He has had previous L2-5 laminectomies on 9/29/20. 
Provided documentation demonstrates subjective and objective deficits that are corroborated 
by imaging studies. Trial and failure of conservative treatment modalities has been 
documented. There is potential impending/inevitable temporary intraoperative instability 
evident. Therefore, spinal surgery (CPT codes 22612, 22853, 63044, 22848, 63042, 22614, 
22842, 22558, 63048, 22585, 63047, 22800 and two inpatient days) is medically necessary for 
the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 61-year-old female enrollee has requested reimbursement for the intermittent limb compression device provided from 8/28/15 through 9/26/15. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees medical condition status post hip replacement. The physician reviewer found there is evidence based clinical practice guidelines and peer-reviewed literature supporting the use of intermittent pneumatic compression for DVT prophylaxis following total hip arthroplasty. Kakkos and colleagues report that the addition of intermittent mechanical leg compression augments the efficacy of anti-coagulation in preventing DVT in patient undergoing both knee and hip replacement. The American College of Chest Physicians state that optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches. Thromboprophylaxis was recommended for up to 35 days post-operatively, with an intermittent pneumatic compression device recommended for a minimum of 10-14 days (Falck-Ytter, et al). In addition, the American Academy of Orthopaedic Surgeons also recommend that patients undergoing elective hip arthroplasty who are not at elevated risk for venous thromboembolism (VTE) or for bleeding should receive pharmacologic prophylaxis and mechanical compressive devices for the prevention of VTE (Mont, et al). In this case, the patient underwent left total hip arthroplasty on 8/28/15 and was prescribed a DVT prophylaxis unit with intermittent limb therapy for 30 days. DVT risk factors for this patient include her age, the magnitude of surgical procedures, the use of a tourniquet, and ambulatory limitations in the post-operative period. Therefore, the intermittent limb compression device provided from 8/28/15 through 9/26/15 was medically necessary for the treatment of the patients medical condition.  Therefore, the device at issue was 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 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for continued outpatient day treatment program/recovery facility care provided from 1/24/15 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 status post intracranial hemorrhage. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. The patient sustained deficits of physical and cognitive function after a stroke in June 2014. She entered into acute rehabilitation with treatment continuing in the form of a day treatment program through May 2015.  Micklewright and colleagues have shown that entry into a comprehensive day treatment program 0-6 months after acquired brain injury is associated with better outcomes than later entry. The services in dispute are day treatment therapies provided from 1/24/15 and onward, seven months post-stroke and forward. The records submitted for review do not demonstrate the patient has deficits of self-care (ADLs) and functional mobility requiring continued intensive rehabilitation beyond 1/24/15. Based on the medical records submitted and the peer-reviewed literature, the continued outpatient day treatment program/recovery facility care provided from 1/24/15 forward was not and is not medically necessary for treatment of the patients medical condition. For the reasons provided, 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: Upheld

Summary Reviewer 

A 48-year-old female enrollee has requested authorization and coverage for Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that dermatomyositis is an idiopathic inflammatory myopathy. In this case, the patient has been diagnosed with dermatomyositis. Her treatment has included prednisone alone. Initial therapy for individuals diagnosed with this disorder includes high-dose glucocorticoid therapy with a taper to the lowest effective dose. Generally, a glucocorticoid-sparing agent is used in combination with glucocorticoid therapy. Treatment includes prednisone in combination with methotrexate, azathioprine or CellCept. In this case, the patient has only been treated with prednisone, and the requested medication is not considered a first-line medication. There is no documentation that she has failed treatment with a glucocorticoid-sparing agent, such as methotrexate, azathioprine or CellCept, which are considered first-line medications. The requested medication, Gamunex-C is not medically indicated. Therefore, Gamunex-C (immune globulin (human) intravenous or subcutaneous solution, 10 gm/100 ml) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 45-year-old male who presented to his provider on 1/12/22. The patient has 
requested authorization and coverage for implant neuro-electrodes  CPT code 64555 (times 
two)  (implantation  of  neuro-electrodes  for  PNS).  The  physician  reviewer  found  that  the 
submitted documentation supports the medical necessity of the requested service. Strand and 
colleagues report that evidence supports the efficacy of PNS for treatment of failed back surgery 
syndrome via subcutaneous peripheral field stimulation and lower extremity neuropathic pain. 
The authors conclude, PNS should be used judiciously as an adjunct for chronic and acute 
postoperative pain following adequate patient screening and positive diagnostic nerve block or 
stimulation trial. Deer and colleagues report that percutaneous PNS of the medial branch nerves 
for the treatment of chronic axial back pain in patients after radiofrequency ablation is effective. 
The authors noted that a majority of patients reported highly clinically significant reductions, 
equal to or greater than 50%, in average pain intensity two months after PNS, with a majority 
experiencing  clinically  significant  improvements  in  functional  outcomes,  as  measured  by 
disability and pain interference. The authors further noted that five months after PNS, 93% of 
patients reported clinically meaningful improvement in one or more outcome measures, and a 
majority experienced clinically meaningful improvements in pain intensity, disability, and pain 
interference. In a prospective multicenter case series study for populations with chronic axial low 
back pain who had failed multiple prior treatments, Gilmore and colleagues found that patients 
treated with percutaneous PNS reported clinically significant reductions in back pain intensity at 
the end of the two months and that a majority reported sustained relief through eight months 
after the start of treatment. The authors further noted clinically meaningful and statistically 
significant improvements in functional and other outcomes, such as depression, opioid analgesic 
consumption, and health-related quality of life. In this case, the patient is status post lumbar 
surgery  with  ongoing  axial  chronic  back  pain.  The  patient  has  diagnoses  of  lumbar  facet 
arthropathy and lumbar degenerative disc disease shown on lumbar MRI, along with a diagnosis 
of  failed  back  syndrome,  which  cause  axial  back  pain.  The  patient  has  tried  and  failed 
conservative therapies. The patient has had positive diagnostic nerve blocks that did not last. In 
this clinical setting, current medical literature supports the requested service as medically 
indicated. Therefore, implant neuro-electrodes  CPT code 64555 (times two) (implantation of 
neuro-electrodes for PNS) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 45-year-old female with a history of transforaminal lumbar interbody fusion at L3-4 and minimally invasive right sacroiliac fusion. The patient has exhausted conservative treatment and has responded with 75% relief to two sacroiliac joint injections on the left. The patient has requested coverage for left sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  This patient has failed conservative treatment for the left sacroiliac joint pain and had positive left sacroiliac blocks with 75% relief of pain. Sacroiliac joint degeneration is a common cause of chronic low back pain. Minimally invasive fusion procedures have demonstrated successful pain relief. Among these implants, the triangular titanium implants are more popular.  The recent medical literature has documented two-year follow-up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. Duhon and colleagues noted sacroiliac joint fusion using triangular titanium implants showed marked improvements in pain, disability and quality of life at two years. Thus, left sacroiliac joint fusion is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.