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

Summary Reviewer 1

The patient is a 19-year-old female with a history of multiple congenital anomalies and borderline intellectual disability. She has a history of coarctation of the aorta with Shone complex and unbalanced atrioventricular canal defect. She had early developmental delays. Intelligence quotient (IQ) testing revealed a full scale IQ of 74. She has executive functioning and memory problems. She also has a history of hypothyroidism. Examination was significant for height at 143.5cm, high and broad forehead with mild temporal sparseness, somewhat broad nasal bridge, slightly upslanting palpebral fissures, narrow and posteriorly-rotated ears with over folded helices and large lobules, short neck, mild scoliosis, brachydactyly with flattened fingertips and shortening of the 4th and 5th metacarpals, and small feet. The patient underwent genetic testing. She has requested reimbursement for FirstStepDX Plus test rendered on 4/14/17. The Health Insurer has denied reimbursement noting that the services at issue were considered investigational for the evaluation of the patients medical condition.  Chromosomal microarray (CMA) is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with developmental delays, intellectual disability (ID), autism spectrum disorders, and/or multiple congenital anomalies (MCA). The yield of CMA in patients with ID or MCA is estimated to be around 10 percent. While findings on CMA may not alter treatment of ID or MCA features themselves in all patients, CMA has become the standard of care for diagnosis in patients with these conditions. Increasing numbers of patients with ID and/or MCA have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ID due to that underlying cause. Additionally, copy number variations on CMA may inform or identify other complications and medical risks, some of which can be screened for and treated. A 2014 study showed that the majority of those with abnormal CMA had findings that directly affected or altered management.  In sum, the FirstStepDX Plus test rendered on 4/14/17 was likely to have been of greater benefit for evaluating this patients medical condition when compared to other options for the treatment and evaluation of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 48-year-old male enrollee has requested authorization and coverage for arthrodesis sacroiliac joint. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with a history of chronic left sacroiliac joint/buttock pain which radiates into the posterior thigh. Significant functional limitations are noted in activities of daily living due to his left sacroiliac joint pain, including sleep disruption. Clinical examination findings have documented positive Fortin finger test for left sacroiliac joint pain and positive sacroiliac joint provocative tests. He had positive short-term response to sacroiliac joint corticosteroid and platelet-rich plasma injections, followed by the return of severe pain. He has failed to achieve adequate sustained relief with prior injection therapy, extensive physical therapy, activity modification, and medications. There is reported imaging evidence of left sacroiliac joint degenerative changes. There is also magnetic resonance imaging (MRI) evidence of L5/S1 spondylolisthesis and neural foraminal stenosis with bilateral L5 nerve root compression. The records documented current normal lumbar spine examination with no lower extremity focal neurologic deficits, and normal bilateral hip examination. A recent L5/S1 selective nerve root block did not provide significant relief of symptoms. It is documented that the lumbar spine and left hip have been ruled-out as the primary pain generators. He has been recommended for minimally invasive left sacroiliac joint fusion. Current evidence-based medical literature and guidelines support the use of the minimally invasive sacroiliac joint fusion in this clinical setting. Therefore, sacroiliac joint arthrodesis is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 54-year-old female enrollee has requested authorization and coverage for surgery to treat her heart rhythm. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of paroxysmal (AF) atrial fibrillation. The physician reviewer found that this patient has a history of symptomatic paroxysmal atrial fibrillation. The records indicate that she has had several hospital stays from 2012 through 2016 with episodes of atrial fibrillation. She has tried two different antiarrhythmic agents. Rythmol, a class IC antiarrhythmic agent, was tried unsuccessfully in 2012. Most recently, in 2016, Multaq (dronedarone), a class III antiarrhythmic agent was also tried. The patient failed Multaq, having had a symptomatic recurrence of AF in August 2016. Based on current American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines for patients with symptomatic AF refractory or intolerant to at least one Class 1 or 3 antiarrhythmic medication which is paroxysmal, catheter ablation is recommended. This patients clinical situation meets accepted, guideline-directed indications for catheter ablation. As such, the requested surgery is likely to be more beneficial than standard therapies available to treat this patients heart rhythm. Therefore, for the reasons stated 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 10-year old male. The patientas parent has requested reimbursement for 92507 (treatment of speech, language) provided from 1/04/20 through 6/27/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The patient has autism spectrum disorder and ADHD, predominantly inattentive subtype He has significant impairment in the appropriate social use of pragmatic language, which is causing difficulty with social interaction with his peers and adults. His language difficulties are also adversely affecting his school performance. The patient will be at significant risk of bullying, anxiety and depression as a result of his language impairment. Recently published guidelines from the American Academy of Pediatrics on the management of children with autism spectrum disorder note, aImprovement in ratings of conversational competence by parents and of classroom learning skills by teachers supports the recommendation for social skills and social language interventions for students with autism spectrum disorder.a The authors noted, aChildren and youth with autism spectrum disorder often have deficits in pragmatic language that can affect social interaction with adults and peers and academic performance as more complex language becomes required for reading comprehension and analysis of information. In addition, literal interpretation of language and difficulty in understanding the intent of other people leads to behavioral challenges in some people with autism spectrum disorder and affects success in school, leisure activities, and employment.a Helland and Helland recommended that the substantial influence of pragmatic language abilities on social function and in resolving interpersonal conflicts with peers needs to be considered in children with autism, and that further development of therapy plans and interventions targeting pragmatics is strongly needed. Therefore, 92507 (treatment of speech, language) provided from 1/04/20 through 6/27/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either class 1 or 2, with class 2 melanomas having a significantly higher rate of recurrence than class 1. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma testing classification in patients undergoing sentinel node sampling. This patient had recurrent melanoma both in skin and lymph nodes, which placed her in a high risk group for further recurrence, and she was already appropriately placed on adjuvant immunotherapy. In this patients case, the records do not demonstrate that DecisionDx-Melanoma testing was likely to have impacted her care or added to the prognostic information already known from her pathology results. Therefore, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 61-year-old female with a history of a thyroid nodule. Fine needle aspiration was indeterminate. The provider recommended Afirma testing. The patient has requested reimbursement for the gene test provided on 12/21/16. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of this patient. The medical evidence supports the services at issue in this patients case. Genetic testing is generally considered standard protocol on all fine needle aspirations done on thyroid nodules. The medical literature indicates that this test can be utilized to avoid unnecessary surgeries. Thus, gene test provided on 12/21/16 was likely to be of greater benefit than other methods 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: Overturned

Summary Reviewer 


A 44-year-old female enrollee has requested reimbursement for the pneumatic compressor device provided on 8/10/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees right lower extremity lymphedema secondary to venous insufficiency. The physician reviewer found the pneumatic compressor device provided on 8/10/16 was medically necessary for treatment of the patients medical condition. There is sufficient support in the medical literature for the device at issue in this clinical setting. Blumberg and colleagues studied the quality of life in patients with lower-extremity lymphedema treated with pneumatic compression. The authors stated that pneumatic compression has been shown to decrease the overall limb girth, as well as the number of infections and skin ulcerations.  The authors concluded that treatment with pneumatic compression improves symptom relief and reduces episodes of cellulitis and ulceration in lower-extremity lymphedema. In addition, Karaca-Mandic and colleagues found an association between use of pneumatic devices and decreased episodes of cellulitis. In this case, the patient presents with lymphedema that has been well controlled with improved quality of life with the use of the pneumatic compression. As such, the pneumatic compressor device provided to the patient was medically necessary for 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 22-year-old female enrollee has requested reimbursement for the blood testing (Prometheus Anser IFX) performed on 4/26/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the patient is a 22-year-old female with Crohns disease diagnosed in 2012. Per the progress note dated 3/2/16, the patient has a stenotic ileocolonic valve and perianal disease. She has been treated with 6-mercaptopurine, Remicade combination therapy, and then Remicade monotherapy at 10 mg/kg every four weeks and then 5 mg/kg every eight weeks with clinical response and remission. She was noted to have fecal calprotectin at 288 and normal C-reactive protein with elevated erythrocyte sedimentation rate. The patient reported to having one to two formed bowel movements per day with no bleeding, urgency, abdominal pain, fever, chills, or active perianal disease. On that date, erythrocyte sedimentation rate was slightly elevated and fecal calprotectin was suggestive of active disease. The provider recommended Anser IFX, colonoscopy and magnetic resonance enterography to assess disease activity. Anser IFX on 4/26/16 showed Remicade level of 8.7 ug/mL and lack of anti-Remicade antibodies. Magnetic resonance enterography showed active disease and led to Remicade dosage increase. The patient has requested reimbursement for blood testing (Prometheus Anser IFX) performed on 4/26/16. The Health Insurer has denied this request as investigational. Prometheus Anser IFX has not definitively demonstrated efficacy for the management of Crohns disease. The presence of antibodies alone does not necessarily result in reactions to infliximab or loss of response to infliximab, nor have threshold levels been established (Steenholdt, et al). Furthermore, studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). In sum, the medical literature reports contradictory outcomes with the use of use of Prometheus Anser IFX and lacks high-quality controlled studies to define drug level or antibody level thresholds requiring action, compare clinical strategies such as dose increase or change in medication based on those thresholds. For these reasons, the blood testing (Prometheus Anser IFX) performed on 4/26/16 was not likely to be more beneficial for treatment of the enrollees 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 2

A 42-year-old female enrollee has requested authorization and coverage for total disc replacement. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there has been a strong interest in cervical disc arthroplasty as an alternative to fusion. While comparative studies with anterior cervical fusion yield similar results, the expectation of a decrease in adjacent segment disease development in long-term studies remains in question. There is also an additional problem with the long-term implications of development of heterotopic ossification. Additional studies are required to allow for this method of treatment to be considered standard of care. These should include an evaluation of the subset of patients who will most benefit from this procedure as well as study of advantages/disadvantages of disc design and surgical procedure in terms of outcomes. Adjacent segment disease seems to be a natural aging process, and artificial disc replacement has not proven any benefit in altering that progression. In this patients case, she is status post C6-7 fusion. She has symptomatic adjacent level disc disease above the fusion at two levels, and has failed conservative management. Cervical disc arthroplasty at multiple levels is not recommended.  Given the lack of superiority and the unknown long-term complications, cervical disc arthroplasty does not currently have enough high quality supporting evidence with long-term follow-up to recommend its routine use over anterior cervical discectomy and fusion for the patients condition.  In sum, the requested total disc replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 76-year-old female enrollee has requested reimbursement for inpatient skilled nursing sub-acute level 1 care provided from 10/30/17 through 11/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition status post pelvic fracture.  The physician reviewer found that based on the presented clinical records submitted for review, inpatient skilled nursing sub-acute level 1 care provided from 10/30/17 through 11/2/17 were medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, there was no documentation of a discharge plan in place as of 10/30/17. In addition, as of 10/30/17 the patient had continued mild deficits of self-care and functional mobility. As such, continued skilled services at the skilled nursing level of care were medically necessary from 10/30/17 through 11/2/17 for treatment of the 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 

The patient is a 36-year-old female who is appealing denial of reimbursement for repair of nasal vestibular stenosis with graft performed on 3/12/20. . The patient has requested reimbursement for repair of nasal vestibular stenosis with graft performed on 3/12/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that Samra and colleagues stated, aNasal valve collapse is a common cause of functional upper airway obstruction that leads to varying difficulty with nasal inspiration, diminished exercise tolerance, and significant decreases in quality of lifeaSurgical management of the nasal valve is focused primarily on widening the valve and providing support to the lateral wall with appropriate autologous grafting techniques.a This patient underwent reconstructive surgery for correction of breathing obstruction secondary to deviated nasal septum and collapsed internal nasal valves. Postoperatively, her nasal airway was further decreased. Physical examination revealed nasal septal deviation to the left side, obstructing approximately 50% of the airway. Both internal valves were compromised from the septal deviation with narrowing of the internal valve angle, and there was a positive Cottle test on both sides. She was reported at surgery to have extremely distorted anatomy and heavily scarred tissue. There was a large amount of scarring in the internal attic of the vestibule on the right side. Based on the medical information received for review and peer-reviewed medical literature, the nasal reconstruction was medically necessary for relief of breathing obstruction. Therefore, repair of nasal vestibular stenosis with graft performed on 3/12/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 23-year-old transgender male who underwent a bilateral mastectomy with nipple/areolar reconstruction on 1/16/19.  The patient has requested reimbursement for nipple/areola reconstruction performed on 1/16/19. The Health Insurer has denied this request and reported that the services at issue were 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 World Professional Association for Transgender Health (WPATH) Standards of Care Version 7 states, Genital and breast/chest surgical treatments for gender dysphoria are not merely another set of elective procedures. Typical elective procedures involve only a private mutually consenting contract between a patient and a surgeon. Genital and breast/chest surgeries {are} medically necessary treatments for gender dysphoria Olson-Kennedy and colleagues also stated that chest surgery is an effective treatment of gender dysphoria in young transmasculine men. The authors noted, Chest dysphoria was high among presurgical transmasculine youth, and surgical intervention positively affected both minors and young adults. In this case, the records documented gender dysphoria. The current medical evidence supports the services at issue in this clinical setting. Therefore, nipple/areola reconstruction performed on 1/16/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for residential treatment services provided from 7/17/15 through 9/29/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees substance abuse disorder. The physician reviewer found in sum, the patients records reflect that he was evidencing unstable vital signs, showed poor judgment, and exhibited potentially unsafe behaviors throughout his stay at the RTC. As such, the residential treatment services provided from 7/17/15 through 9/29/15 were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.