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

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for the mobile heart monitor provided on 8/2/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees palpitations. The physician reviewer found that the largest multicenter controlled trial to date using real time CardioNet event monitoring included 266 patients with persistent symptoms who had previously undergone prior Holter monitoring which failed to diagnose an arrhythmia (Rothman, et al). Another retrospective analysis of 100 consecutive patients who were undergoing treatment for known arrhythmias using real time monitoring devices showed that a number of treatment changes were made based on findings from the real time monitors, but there was no follow-up to determine whether patient outcomes were improved as a result of this new information (Joshi, et al). Other studies have shown benefit with regard to the diagnostic yield of finding arrhythmias requiring treatment using mobile telemetry event recorders over traditional Holters or event monitors (Olson, et al; Kadish, et al). Given the published data suggesting a higher diagnostic yield of the real time monitored device, along with a higher pre-test probability of an atrial rhythm disturbance, the use of mobile telemetry recording was reasonable. It ultimately also provided clinical information which resulted in diagnosis of the condition, and since the clinical symptoms in the patient diary correlated with the mild rhythm disturbances noted, the data supported a definitive diagnosis. Accordingly, the mobile heart monitor provided on 8/2/17 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 19-year-old female with a history of low back pain. The patient has requested authorization and coverage for anterior lumbar fusion, allograft synthetic cage and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Anterior lumbar interbody fusion is associated with higher fusion rates compared with posterolateral lumbar fusion in patients with degenerative changes of the lumbar spine, including those with instability.  There is moderate evidence that for lumbar degenerative disc disease without instability, a standalone anterior lumbar interbody fusion has better clinical outcomes than the anterior lumbar interbody fusion plus instrumented open posterior lumbar fusion. This patient has not responded to conservative treatment and is likely to benefit from the anterior lumbar interbody fusion. As such, the requested anterior lumbar fusion, allograft synthetic cage and associated inpatient stay are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 39-year-old female who underwent genetic testing during pregnancy.  Specifically, she underwent testing for the SMARCA4 gene mutation. The patient had a prior affected child with the SMARCA4 gene mutation leading to the child having Coffin-Siris syndrome. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. Per the records, there is a higher chance than the general population that the fetus may have the gene mutation SMARCA4 leading to Coffin-Siris syndrome.  Since this patient already had a severely affected offspring, the information from this testing was important in making important medical decisions regarding the pregnancy. Thus, SMARCA4 gene mutation and chromosome testing performed on 8/14/17 were likely to be of greater benefit than other modalities for 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 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with inflammatory bowel disease, psoriasis and juvenile ankylosing spondylitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. Cimzia is an anti-tumor necrosis factor medication which is indicated for the treatment of psoriasis, inflammatory bowel disease and ankylosing spondylitis/sacroiliitis. These diseases are the same in children and adults and respond to therapy similarly. Currently, there is an active trial being conducted, the Pediatric Arthritis Study of Certolizumab Pegol (PASCAL). This is a phase 3, multicenter, open-label study to assess the pharmacokinetics, safety, and efficacy of certolizumab pegol (Cimzia) in children and adolescents with moderately to severely active polyarticular-course juvenile idiopathic arthritis. In this patients case, Cimzia is a medically appropriate treatment option. Thus, Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications are medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 51-year-old female patient. Notes dated 9/2/22 reported that the patient presented 
on 8/5/22 with mid-back pain after lifting her 80 pound dog three months ago. The patient has 
requested authorization and coverage for kyphoplasty and vertebroplasty. The Health Insurer has 
denied this request and reported that the requested services are 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 submitted documentation supports the medical necessity of the requested 
services. Kyphoplasty can be used for a variety of clinical and radiographic findings. It may 
provide rapid pain relief in patients with spinal compression fractures, whether osteoporotic or 
traumatic in nature. Although there is significantly more literature addressing the osteoporotic 
population, these findings may be extrapolated to patients with traumatic compression fractures 
and  acute  vertebral  body  pain.  Vertebroplasty  is  similarly  clinically  useful  in  significantly 
decreasing pain in patients with acute spinal compression fractures. The differences between these 
two procedures are  subtle, including initially greater vertebral body height restoration  with 
kyphoplasty. Additionally, there appears to be a slightly greater incidence of cement extravasation 
in vertebroplasty as compared to kyphoplasty. These differences do not appear to be clinically 
significant. In this case, the patient experienced an onset of acute thoracic pain after lifting a heavy 
object. Given that current medical literature supports the treatment of such pain with kyphoplasty 
and vertebroplasty for rapid pain relief and a return to normal functioning, the requested services 
are medically indicated. Therefore, kyphoplasty and vertebroplasty are medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested reimbursement and prospective authorization and coverage for the ventilator positive airway pressure (VPAP) durable medical equipment provided from 8/2/14 forward. The Health Insurer has denied this request indicating that the device at issue was not and is not medically necessary for treatment of the enrollees severe sleep disordered breathing.  The physician reviewer found that the records indicate that this patient has severe obstructive sleep apnea. He did not respond to standard CPAP or BiPAP, and VPAP was initiated. The patient has been compliant with the therapy, and is responding well to it. VPAP is an advanced form of autotitrating BiPAP therapy and is indicated in this case to treat this patients obstructive sleep apnea. Thus, the VPAP durable medical equipment provided from 8/2/14 forward was and is medically necessary. Given these findings, the device at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage for Sovaldi for 24 weeks. The Health Insurer has denied this request indicating that the requested medication is medically necessary for treatment of the enrollees medical condition. The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Patients with cirrhosis are reported to be high priority for treatment. The guidelines recommend specialist treatment for patients with decompensated cirrhosis, which is met in this case. The guidelines also recommend 12 weeks of Sovaldi and Daklinza with low-dose ribavirin for decompensated patients with genotype 3 hepatitis C, based on clinical study data (Foster, et al; Nelson, et al). The guidelines recommend that genotype 3 patients who have failed treatment with Sovaldi and ribavirin (regardless of cirrhosis status) should be treated with Sovaldi, Daklinza, and ribavirin for 24 weeks. This is based partially on the results of the ALLY-3 study, which demonstrated poor cure rates of only 71% in Sovaldi-experienced patients after 12 weeks of Sovaldi and Daklinza therapy (Nelson, et al; Leroy, et al). For these reasons, the requested treatment with Sovaldi to be used with Daklinza and ribavirin for 24 weeks is medically necessary for treatment of the patients hepatitis C infection. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 22-year-old male enrollee has requested reimbursement for partial hospitalization program services provided from 11/2/15 through 12/2/15; and intensive outpatient program services provided on 12/23/15; and outpatient psychiatric group counseling from 12/23/15 through 3/21/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the partial hospitalization program services and intensive outpatient program services during the dates in dispute were not medically indicated for this patient. According to the documentation submitted for review, the patient was not in withdrawals. He did not experience PAWS. He was not a danger to himself or others. He was medically and psychiatrically stable. His medication management could have taken place on an outpatient basis. He was cooperative and motivated. The patient could have been treated at a lower level of care from 11/2/15 through 12/23/15. Outpatient group counseling would have been a sufficient and appropriate level of care for ongoing treatment in conjunction with community based supports such as a 12-step program. Given the above, outpatient psychiatric group counseling from 12/23/15 through 3/21/15 was medically indicated for the treatment of the patients medical condition. Therefore, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 43-year-old male enrollee has requested reimbursement for Anser IFX testing performed on 8/09/15.  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 medical evidence supports the services at issue for the management of this patient with Crohns disease.  The documentation noted that he was being treated with Remicade infusion and reported back pain and abdominal pain.  The purpose of measuring the drug level and antibodies to the drug is to optimize therapy to achieve therapeutic response and induce remission in patients with active Crohns disease, and to also to help the treating provider to make a decision to switch to a different biologic in the event the patient has developed an antibodies to the drug.  Thus, Anser IFX testing performed on 8/09/15 was likely to have been more beneficial than other modalities for 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The American Society for Colposcopy and Cervical Pathology issued its Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors. The recommendations noted, After abnormal cervical cancer screening test results for patients 25 years or older, colposcopic biopsy results, or treatment of histologic high-grade squamous intraepithelial lesion (HSIL), surveillance with either HPV testing alone or cotesting is preferred (AI). Surveillance with cervical cytology alone is acceptable only if testing with HPV or cotesting is not feasible. This recommendation was based on the following rationale, Individuals treated for histologic HSIL or with a recent abnormal screening test result have an elevated risk of cervical precancer warranting close follow-up. HPV testing and cotesting are more sensitive than cytology alone in detecting CIN 2+ in both the post-colposcopy and post-treatment settings. Based on these recommendations and on the fact that this patient has not been following up as recommended, the HPV testing was likely to have been more beneficial than a Pap smear alone. Therefore, HPV testing performed on 9/29/20 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 48-year-old female who has been diagnosed with ulcerative colitis status post colostomy and J-pouch, complicated by chronic pouchitis, and anemia. She has had pouchoscopy several times. The physician reviewer found that fecal calprotectin testing is supported for the management of patients with ulcerative colitis to prevent invasive interventions, such as colonoscopy. A randomized, prospective, controlled trial in ulcerative colitis performed by Lasson and colleagues showed lower relapse rate than control when using calprotectin to direct management with medications. Another prospective study by Scaioli and colleagues demonstrated the utility of calprotectin to lead decision-making in patients with ulcerative colitis. The test allowed for assessment of ulcerative colitis disease activity without colonoscopy. American College of Gastroenterology guidelines state, Fecal calprotectin (FC) can be used in patients with ulcerative colitis as a noninvasive marker of disease activity and to assess response to therapy and relapse. Additionally, the use of the test is supported by extensive literature for the reliable assessment of pouchitis and pouchitis disease activity level. In this case, the patient had ongoing symptoms and anemia despite treatment, consistent with uncontrolled disease activity. Therefore, fecal calprotectin assay performed on 4/19/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has requested coverage for finasteride for the treatment of androgenetic alopecia.  While finasteride has been shown to regrow hair in this condition, its use is considered cosmetic with no effect other than improving the appearance of the patient. Consequently, its use is not considered to be medically indicated.  All told, the requested finasteride tablets 5 mg 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 30-year-old male enrollee has requested reimbursement for assistant-at-surgery services for surgery (64999-AS) performed on 1/09/19. 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 most surgical procedures, especially major procedures, require an assistant. There were three descriptive codes listed in the operative report, and only the bronchoscopy could be completed solely by the primary surgeon. The robotic-assisted rib resection and neurolysis required coordinated teamwork to facilitate a safe and adequately exposed surgical field. When the surgeon is at the console, the assistant controls instrument placement and suction retraction. Similarly, when part of the procedure is open, the assistant retracts and provides access to prevent injury to adjacent structures.  When re-docked and the neurolysis is completed by freeing the strictured vein, the assistant provides counter-tension, once again protecting other vascular structures and brachial plexus from injury. This patient underwent a major thoracic procedure with a high incidence of neurovascular complications. The current medical evidence supports the services at issue in this clinical setting. Therefore, assistant-at-surgery services for surgery (64999-AS) performed on 1/09/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 63-year-old female who presented to her provider on 4/26/23. The patient has 
requested authorization and coverage for dexlansoprazole (Dexilant) 60 mg DR capsule. 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. 
The  records  do  not  document  any  physiologic  reason  why  generic  dexlansoprazole  or 
lansoprazole would not provide the equivalent beneficial effect as Dexilant. Grady and colleagues 
explain that dexlansoprazole is the R(+)-enantiomer of lansoprazole. Current medical literature 
does not show that dexlansoprazole is more effective than the double enantiomer parent 
molecule, lansoprazole. Dexlansoprazole/Dexilant is the R-enantiomer of lansoprazole packaged 
in a special delivery system to work 24 hours per day at a dose of 60 mg. Lansoprazole, at 30 mg 
twice daily, would provide full acid inhibition for 24 hours per day and would be as good or better 
than dexlansoprazole 60 mg. Therefore, dexlansoprazole (Dexilant) 60 mg DR capsule is not 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 this patient has been maintained on Humira but developed relapse of symptoms.  Anser ADA testing measures the Humira blood level and detects antibodies to Humira.  Patients with detectable levels and no antibodies will have to have a change in treatment management in order to control their disease, as the test implies an escape phenomenon to Humira.  Patients with undetectable levels and antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease.  Also, patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. In this case, the patient responds to a higher dose and/or a higher frequency, or both.  It is important for the treating provider to have a roadmap of the nature of the patients clinical course.  There is sufficient support for Anser ADA testing in this patients case.  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.