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

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that in this case, the patient had severe dysphagia with an inability to tolerate solid food intake and a hiatal hernia, with upper gastrointestinal series showing reflux. Hernia repair surgery was being contemplated before the endoscopy with pH study. This is consistent with current medical literature, which recommends a pH study to evaluate esophageal motility before undergoing such a surgery. Additionally, dysphagia in the setting of dilated and angulated esophagus can be suggestive of achalasia, and warrants evaluation with impedance and with esophagogastroduodenoscopy. Furthermore, esophagogastroduodenoscopy is recommended for the evaluation of dysphagia. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 61-year-old female with a history of attention deficit hyperactivity disorder (ADHD) and malabsorption syndrome status post Roux-en-Y gastrojejunostomy in 2003. A letter from the patients provider indicates that she has a history of binge eating disorder. Per the provider, the patient has been stable on Vyvanse 70 mg three times per day since 9/3/12. The patient has requested authorization and coverage for Vyvanse 70 mg three times a day (TID). The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational. 
Treatment guidelines or ADHD for adults indicate that a failure of stimulant medications should be followed by a trial of treatment with alternative medication such as atomoxetine or bupropion. This patients records do not include documentation of trial and failure of non-stimulant type medications. Moreover, the current treatment guidelines do not support the safety of the requested medication dosage. The literature does not support the use of Vyvanse above the FDA recommend maximum of 70 mg per day. All told, the requested Vyvanse 70 mg TID is not supported as medically necessary for treatment of this patients medical condition.  Based upon the information set forth above, the requested medication dosage is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low back pain. The physician reviewer found that pain from degenerated or damaged vertebral 
endplates can trigger inflammation and result in chronic low back pain. Basivertebral nerve 
ablation is a minimally invasive treatment for the relief of chronic low back pain (Fischgrund, et 
al.).  The  authors  concluded  that  patients  with  chronic  low  back  pain  who  underwent 
basivertebral  nerve  ablation  have  exhibited  significantly  greater  improvement  after  three 
months than patients who continued with non-operative care.  This patients MRI showed 
degenerative endplate changes in the L4 and L5 vertebral bodies. Earlier records indicate the 
possibility of lumbar radiculopathy, but the current assessment does not include the diagnosis. 
The records indicate that the patients low back pain has significantly inhibited bending, lifting, 
and sitting. Additionally, this patient has exhausted conservative treatment such as physical 
therapy and home exercise. The patient has been treated with Gabapentin, Meloxicam and 
methocarbamol without relief.  Given these findings, the requested intraosseous basivertebral 
nerve ablation (CPT code 64628) is likely to be more beneficial than any other available standard 
treatments for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 41-year-old male with a history of ileocolonic Crohns disease since 2016. The 
patient has requested authorization and coverage for Humira 40 mg weekly for four months. The 
physician reviewer found that Humira 40 mg weekly is being requested. Empiric dose-escalation 
or guided by therapeutic drug monitoring is an appropriate intervention for patients with loss of 
response  to  biologic  therapy  per  guidelines  set  forth  by  the  American  Gastroenterology 
Association. A systematic review and meta-analysis by Srinivasan and colleagues showed that 
dose-intensification is clinically effective in patients with Crohns disease with secondary loss of 
response. The patient had initial response to Humira every other week, but had recurrent 
symptoms, which represents loss of response. The patient now has been on dose-escalation with 
weekly dosing, and now has clinical remission. Thus, Humira 40 mg weekly for four months is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 65-year-old female whose tumor was sent for FoundationOne CDx testing. Magnetic resonance imaging (MRI) of the brain showed multiple brain metastases, and a positron emission tomography (PET) scan was negative. The physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing to predict candidates for specific mutation-driven treatment holds promise, but is not yet ready for routine clinical use. Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. This patient underwent next generation sequencing prior to initiation of systemic therapy, despite molecular targets found on biopsy, estrogen and HER2. The use of next generation sequencing continues to be the subject of ongoing clinical trials and use outside of a clinical trial at this time is not indicated. Therefore,
FoundationOne CDx Testing performed on 4/17/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2
A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that there is sufficient support in the medical literature for the efficacy of the requested procedure in this clinical setting. The patient is still morbidly obese. The medical evidence appears to show that patients with diabetes of several years duration are less likely to have complete remission. The antidiabetic effects of bariatric surgery focus on both weight loss and an alteration in the gut hormone milieu with duodenal exclusion. The duodenal switch procedure excludes the duodenum. In this patient, she did lose weight with her initial surgery but her diabetes has returned, despite an almost 20 point loss in her BMI. In sum, there is support for revisional surgery in this patient who has already undergone a primary operation for weight loss. As such, the biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are likely to be more efficacious than the available standard therapy for the treatment of this patient. 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 50-year-old male enrollee has requested reimbursement for Guardant360 testing performed on 8/31/18. 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 there is sufficient support for a portion of the services at issue. The records document non-small cell lung cancer. The patients provider recommended Guardant360 testing, and this was performed on 8/31/18. The medical evidence supports EGFR, ALK, ROS1, BRAF, MET, RET and ERBB2, as these are actionable mutations. There is a lack of support for the other mutations which were tested. Thus, a portion of the services at issue was likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. 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 the current medical evidence does not support the services at issue in this clinical setting.  The patient is being treated with subcutaneous immunotherapy for mast cell disease, food allergy and multiple chemical sensitivities.  Per the literature, subcutaneous immunotherapy using preparations of aeroallergens may be indicated in specific clinical settings.  Studies have demonstrated that patients with both asthma and allergic rhinitis derive particular benefit.  In this case, the patient does not have a diagnosis that is appropriate for subcutaneous immunotherapy.  Therefore, the superior efficacy of the services at issue has not been established.  Based upon the information set forth above, the services at issue were 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 10-year-old female enrollee has requested authorization and coverage for rizatriptan, nine tablets per day. The Health Insurer has denied this request and reported that the requested medication quantity is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with chronic migraine, which is unresponsive to ibuprofen when she is having a severe episode. Rizatriptan 10 mg effectively relieves the pain. Her provider noted that the patient is having more than four severe headaches per month, and she has recommended nine tablets per month, using the medication no more than twice per week. This is in keeping with the dose recommendations by the manufacturer of rizatriptan. Sometimes a second dose of rizatriptan is required if the headache does not respond to the first 10 mg tablet. The medical evidence supports the requested medication quantity in this clinical setting. Barbanti and colleagues and Evers noted the efficacy and safety of rizatriptan in the treatment of pediatric migraine. Therefore, rizatriptan, nine tablets per month are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 36-year-old male with a history of gastroesophageal reflux disease (GERD) for more than 12 years, with breakthrough symptoms of upper abdominal burning and sour taste despite proton pump inhibitor (PPI) use. His symptoms interfere with sleep. An endoscopy on 7/30/15 showed an irregular Z-line and a hiatal hernia. A video esophagogram on 12/16/15 showed no hiatal hernia or spontaneous reflux, but there was reflux to the clavicles with vigorous Valsalva maneuver, followed by spontaneous clearing. An esophageal manometry on 1/4/16 showed normal motility and a decreased lower esophageal sphincter pressure. An endoscopy on 3/7/16 showed a normal esophagus and mild antral gastritis. A pH study on 3/7/16 showed markedly elevated acid exposure. Per the provider letter dated 3/27/17, the patient has failed treatment with omeprazole and ranitidine, and has symptoms including chest pain and pressure, difficulty swallowing, and bloating. The patient has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX device. The Health Insurer has denied this request as investigational. There is a lack of medical literature supporting the efficacy of TIF for the treatment of GERD. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF with anti-reflux surgery (Auyang, et al). SAGES concluded that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety (Auyang, et al). These conclusions are supported by recent reports of adverse events during the procedure and the need for surgery to revise ineffective TIF (Ashfaq, et al; Bell, et al; Edriss, et al). For these reasons, the request for TIF with EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement for anesthesia services performed on 12/18/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary during the enrollees colonoscopy procedure. The physician reviewer found the American Society of Anesthesiology (ASA) physical status classification system is utilized to assess the fitness of patients before surgery. According to the submitted record, the patient had an ASA preoperative physical status classification score of 2, which indicates no functional limitations. There is no documentation of clinical findings that would support the need for monitored anesthesia in this patients case. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist are well supported in both clinical practice and in the research. Therefore, given a low preoperative physical status classification score of 2, the anesthesia services performed on 12/18/15 were not medically necessary during the patients colonoscopy procedure. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 36-year-old male with a history of lumbar radiculopathy; lumbar spondylosis; disc 
degeneration  of  the  lumbar  spine;  and  lumbar  stenosis  with  neurogenic  claudication.  The 
providers examination on that date revealed negative straight leg raise bilaterally and normal 
sensation with decreased strength in bilateral hip flexion and ankle dorsiflexion. The providers 
treatment plan included an L5-S1 axial lumbar interbody fusion (ALIF) and posterior spinal fusion 
(PSF). The Health Insurer has denied the requested services as not medically necessary for the 
treatment of the patient. Therefore, the Health Insurer has denied coverage for the requested 
services. This denial is the subject of this appeal and determination. The physician reviewer found 
that medical literature establishes that a trial of conservative therapy may be considered for patients 
with low-grade spondylolisthesis presenting with radiculopathy and/or pseudo-claudication. These 
options  may  include  physical  therapy,  epidural  steroid  injection,  and  pain  medications.  If 
unresolved, surgical options may include decompression alone or decompression and fusion 
(Bydon,  et  al.).  Further  collaboration  was  provided  by  Eismont  and  colleagues  who  found 
Treatment begins with a trial of nonsurgical methods, including physical therapy, NSAIDs [non-
steroidal anti-inflammatory drugs], and epidural corticosteroid injections. Surgical treatment with 
decompression and fusion is recommended for patients who do not respond to this initial regimen. 
Further,  this  view  was  accepted  by  Chan  and  colleagues  who  indicated  that  patients  with 
symptomatic lumbar spondylolisthesis should first be treated with conservative management 
strategies  including  non-narcotic  and  narcotic  pain  medications,  epidural  steroid  injections, 
transforaminal injections, and physical therapy. In this case, a review of the record does not reveal 
a trial and failure of recent, reasonable, comprehensive, and less invasive conservative care 
measures. The patient is noted to have had a recent course of physical therapy; however, it is not 
clearly documented. Additionally, there is limited documentation supporting treatment with recent 
epidural steroid injections. Moreover, dynamic flexion and extension films were not provided in 
order to assess the amount of movement at the requested surgical level. Furthermore, detailed 
documentation  is  not  evident  regarding  potential  impending  or  inevitable  temporary  intra-
operative instability. In addition, there are limited large-scale, long-term references showing the 
safety and efficacy of the requested surgery in this clinical setting. Therefore, the requested L5-S1 
ALIF and PSF are not medically necessary for the treatment of the patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for residential psychiatric treatment from 11/16/15 through 7/30/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. On initial evaluation, the patient was noted to have mood lability, anhedonia, passive suicidal ideation, impulsive behaviors, and poor relationships with peers and family.  During admission to the residential facility, the patient was documented as being grandiose at times, irritable, suspicious of others, anhedonic, and guarded. She was not consistent with completing her activities of daily living and struggled with school assignments. She had difficulty with interacting with peers and would display oppositional behavior towards staff. She also had some difficulties tolerating medications. Aripiprazole was documented as causing confusion and spaciness.  This medication was discontinued on 2/17/16 but subsequent progress notes indicated that the patient continued to struggle with her mood.  From 5/19/16 through 5/22/16, the patient was documented as having a manic episode triggered by medication changes. During this manic episode, the patient also reported hallucinations and delusions and staff had difficulty managing her behavior. She was started on quetiapine and benztropine. She complained of blurry vision and her dose of quetiapine was lowered. On 7/18/16, the patient was documented as having continued irritability and dose of quetiapine was increased.  The record noted that the patients medications were adjusted up until the time of discharge. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and documentation as outlined above, the patient met CASII criteria for 24 hour psychiatric monitoring during the disputed dates. The patients clinical status, in addition to current medical literature, support the treatment she received at the residential level of care. Accordingly, residential psychiatric treatment from 11/16/15 through 7/30/16 were medically necessary for the treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 14-year-old female who has been diagnosed with autism spectrum disorder. On 
10/05/21, the provider requested 16 hours per week 1:1 applied behavior analysis (ABA) therapy 
per week and 8 hours supervision per month. The physician reviewer found that the submitted 
documentation fails to demonstrate the medical necessity of the services at issue. Specifically, 
the intensity approved by the Health Insurer (12 hour per week 1:1 ABA therapy and 6 hours per 
month supervision) is the appropriate treatment frequency. The medical record included several 
treatment plans indicating the patient has made progress over their course of treatment with the 
provider over the last several years. Challenging behavior has reduced, and the number of 
targeted  goals  have  also  reduced  over  the  last  several  treatment  authorization  requests. 
However, the patient's Vineland scores have decreased over this same period of time. Even with 
this decrease over time, all scores on subdomains (communication, daily living, and socialization) 
are within or just beyond the threshold of one standard deviation from the mean. These score 
highlight that the patient is functioning within, or close to, the average range (in the identified 
subdomains) compared to same aged peers. While the patient still demonstrates a need for 
support, treatment intensity can be faded.