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

Summary Reviewer 


A 19-year-old male enrollee has requested reimbursement for residential treatment center (RTC) substance use disorder treatment services provided from 2/9/16 through 4/25/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees depression and cannabis related disorder. The physician reviewer found that based on the records provided for review, the RTC substance use disorder treatment services provided from 2/9/16 through 4/25/16 were not medically necessary. The patient was cooperative in treatment and could have been safely and adequately treated in a less restrictive setting. The progress notes from the disputed period indicate that the patient was cooperative in treatment and open to therapy. The patient did not express suicidal ideation or severe mood lability during the disputed period. Moreover, the patient did not have any self-harm behaviors, was medically stable, and did not demonstrate any withdrawal symptoms. As RTC services are considered the highest level of psychiatric care available, medical necessity guidelines and evidence-based practice indicate that a patients psychiatric symptoms must be severe and present to the degree that this level of care is needed. Applying the Level of Care Utilization System (LOCUS), this patient was a candidate for low intensity community based services. The patient was a low risk of harm, his functional status was mild, and he had no medical instability or severe psychiatric issues. In addition, the patient had a stable living and recovery environment, and was cooperative in treatment and provided insight into the need for treatment. Similarly, according to the American Society of Addiction Medicine (ASAM), the patient had mild emotional/behavioral or cognitive conditions and complications that were stable, had minimal motivation, and has a risk for relapse due to a minimal period of sobriety, amenable to treatment with intensive outpatient services, nine or more hours of service per week. Given these findings, the RTC substance use disorder treatment services provided from 2/9/16 through 4/25/16 were not medically necessary for treatment of this patients medical condition. Based on these findings, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 65-year-old female enrollee has requested authorization and coverage for proton beam radiation therapy. 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 in the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using IMRT. However, in this case, the patient has undergone radiation to the area once in 1987. Treatment with protons would be expected to reduce the integral dose to the surrounding structures such as the brainstem, spinal cord, temporal lobe and oral cavity compared to standard treatment with photons. This would result in a meaningful reduction in acute and long-term toxicities compared to treatment with standard photons due to the patients past history of radiation therapy to this site. All told, the requested proton beam radiation therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 62-year-old male who had a prostate biopsy on 7/11/16. At that time, his prostate specific antigen score was less than 10. Of 14 cores taken, one was positive for Gleason 3+3 (6) adenocarcinoma, occupying 8% of the core. A tissue sample was sent for OncotypeDx assay. The patient has requested reimbursement for gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17. The Health Insurer has denied this request and noted that the services at issue were investigational for evaluating this patients medical condition. The standard of care after the initial diagnosis of localized prostate cancer is to determine a specific cancer treatment such as surgery or radiation therapy, or undergo active surveillance, with no specific treatment at that time. A recommendation is made based on risk stratification, which is a methodology placing each man into a risk category for which a treatment can be recommended. The stratification is mostly based on the prostate specific antigen and specific pathologic findings at biopsy. Applying this methodology to this patient, he falls into a very low risk category, for which surveillance alone would be the recommendation. A further refinement of prognostication is the use of gene panels, such as OncotypeDx. This is a 17 gene panel that seems capable of predicting the risk of recurrence after treatment, such as surgery, for the prostate cancer (Cheville et al; Cullen, et al). While there have been multiple genetic profiles studied to investigate whether these assays might add to the accuracy of prognostic categorization by risk assessment, these tests have not yet been shown to be reliable in altering clinical decision making, particularly in patients assessed in the very low risk category, such as is the case in this patient. All told, the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17 was not likely to have been of greater benefit over the standard methods of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation 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 41-year-old male enrollee has requested reimbursement for chiropractic treatment provided from 3/30/15 through 11/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees chronic pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has had an excessive amount of chiropractic care with no objective improvement.  The submitted functional indexes are almost identical.  When further clinical improvement cannot be reasonably expected from continuous ongoing care, the treatment is considered maintenance therapy and is not medically necessary.  The current medical evidence does not support the services at issue in this clinical setting.  All told, chiropractic treatment provided from 3/30/15 through 11/30/15 were not medically indicated for the treatment of this patient. Therefore, the services at issue were 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 

The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential treatment provided from 9/22/14 through 11/11/14.  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 submitted documentation fails to demonstrate the medical necessity of the services at issue.  The reasons or precipitating factors for the patients admission on 9/22/14 are unclear.  He was not a danger to himself or others.  Per the records, he was not violent or aggressive, and he showed no self-harm urges.  The patient was not on any medication, and he lived with his parents in a supportive environment.  There is no comprehensive admission assessment by a physician.  There is only a one paragraph intake assessment by a therapist.  There is no psychosocial history, prior medical history or psychiatric history.  There were no diagnoses provided.  The records do not include physician notes, nursing notes, treatment plans or group notes except for the group note dated 10/13/14.  The documentation is scanty at best and provided no insight as to what the patient was doing on a day to day basis, what services were rendered, or what benefit he received from these services.  This is not consistent with care that would or should be given at a residential treatment center.  This aside, the patient did not require 24-hour supervision in a restricted, structured setting.  He could have received continued evaluation and treatment at a lower level of care.  All told, mental health residential treatment provided from 9/22/14 through 11/11/14 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 53-year-old female who had developed malignant melanoma on the skin of right medial thigh with a Breslows depth of approximately 0.4 mm. The DecisionDX-Melanoma gene assay performed on 9/15/17 revealed Class 1A molecular signature associated with a low risk of recurrence within five years. The patient has requested reimbursement for the genetic testing performed on 9/15/17, but the Health Insurer denied this request indicating that the services at issue were considered investigational for evaluation of the patients cutaneous melanoma.  There is a lack of peer reviewed published studies as to this tests superior efficacy when compared to other standard modalities. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1, consistent with a low risk of metastasis, or class 2, suggestive of a high risk of metastasis. While the majority of clinical stage I patients will be disease free at five years, some stage I patients will develop advanced disease. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term within five years metastatic disease. In sum, while there is some support in the medical literature for the efficacy of the services at issue, genetic testing performed on 9/15/17 was not likely to have been of greater benefit than the available standard methods for the evaluation of patient.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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: Overturned

Summary Reviewer 3


A 52-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 7/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees colonic Crohns disease. The physician reviewer found the testing at issue was likely to be more effective for this patient than other available treatment options. The patient presents with inflammatory bowel disease (IBD), namely Crohns disease. The Prometheus Anser IFX test measures the Humira blood level and detects antibodies to Humira. The clinical indication for testing was to ensure adequate levels, lack of antibodies and to determine whether her symptoms were likely related to Crohns disease versus an alternate diagnosis. Due to the multitude of management options once a patient loses response to Humira or has unexplained episodic symptoms that could be attributed to disease flares and the fact that these medications have a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. The Prometheus Anser IFX test provides such a roadmap and was likely to be more beneficial for evaluation and treatment of the patients Crohns disease than other modalities. Based upon the information set forth above, the testing at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center (RTC) services provided from 11/7/16 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 attention deficit hyperactivity disorder (ADHD) and anxiety.   The physician reviewer found the records do not demonstrate that this patient reported suicidal or homicidal ideation or demonstrated psychosis during his RTC admission from 11/7/16 forward. The patient had continued symptoms of oppositional behavior and periods of intense emotions but had not engaged in any self-harm behaviors. He was not displaying any significant or severe behavioral problems during the disputed period. Thus, although he needs treatment to further improve his social functioning, impulsive behaviors, and sexual maladaptive behaviors, as of 11/7/16, he no longer required the restrictiveness of a residential psychiatric treatment facility. The records indicate that he has stabilized over the five months of residential care at the facility to support transition to a less restrictive setting. Outpatient treatment and least restrictive options are considered first-lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (AACAP), which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports (Winters, et al). The treatment goals listed by the residential treatment center could be accomplished on an outpatient basis and are treatment goals that are typically listed for outpatient level of care. Accordingly, the psychiatric RTC services provided from 11/7/16 forward were not and are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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: Experimental
Decision: Upheld

Summary Reviewer 2

The parent of a 16-year-old female enrollee has requested authorization and coverage for Rituxan. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Rituximab has not been approved by the U.S. Food and Drug Administration (FDA) for the diagnosis of juvenile idiopathic arthritis (JIA) but is approved for adult rheumatoid arthritis. This medication has been not been studied extensively in JIA. There are currently no national guidelines or large randomized controlled studies recommending this therapy for JIA. The current guidelines recommend a trial of a second TNFi.  In this case, the patient has failed methotrexate and Humira.  The guidelines would recommend a second TNFi, tocilizumab or abatacept over rituximab.  The medical records fail to demonstrate any extenuating circumstances for going against the guidelines. All told, Rituxan is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/29/15.  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 in this patients case.  Breast tomosynthesis allows radiologists to separate dense glandular elements from underlying architectural distortion.  In this case, the use of breast tomosynthesis helped to characterize the initial lesion as suspicious and allowed the radiologist to evaluate the remainder of the right breast for a potential synchronous mass as well as clearing the left breast.  The use of breast tomosynthesis has resulted in a decrease in callbacks and increase in detection of small cancers in screening populations.  Thus, the inclusion of breast tomosynthesis in the diagnostic mammogram of 7/29/15 was likely of more benefit to the patient than if she had a two-dimensional study alone.  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 


A 22-year-old male enrollee has requested reimbursement for substance use intensive outpatient program services provided from 2/03/15 through 4/29/15.  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 submitted documentation fails to demonstrate the medical necessity of the services at issue.    It appears that his last alcohol use was two to four months before presentation while his last marijuana use was in December 2014.  Aside from nicotine use and hashish experimentation, the patient had no other substance use history.  The patients strengths included his motivation for recovery, therapeutic engagement, stable housing and a supportive family willing to participate in his care.  Although the patient had elements consistent with a formal thought disorder in absence of substance use, his symptom burden was being addressed with psychiatric services and pharmacotherapy, and did not necessitate services at the intensive outpatient program level of care.  On 2/02/15, the treatment plan called for 12-step programming, increased relapse prevention and improved awareness of family and life stressors.  Since the patient had no prior history of chemical dependency treatment and family therapy in the outpatient setting, there is no evidence to suggest that outpatient services with community programming would have been insufficient in attaining said treatment goals. Thus, based on the clinical presentation coupled with relevant peer-reviewed medical literature and current practice guidelines, substance use intensive outpatient program services provided from 2/03/15 through 4/29/15 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were 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 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for physical therapy from 5/02/16 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 medical condition. The physician reviewer found the literature related to rehabilitation after anterior cruciate ligament reconstruction supports early weight-bearing, early range of motion exercise, and closed kinetic chain activities.  The early rehabilitation process should be monitored closely to protect against graft failure and other complications.  As strength improves, open kinetic chain activities and more functionally advanced work can be introduced, although demanding physical activity is generally avoided during the first three postoperative months.  Overall, rehabilitation following anterior cruciate ligament reconstruction can require a prolonged period of time.  However, the entire rehabilitation process following anterior cruciate ligament reconstruction does not require a formal therapy setting.  In this patients case, the therapy interventions and modalities which have been provided have included manual therapy, supervised exercise, home exercise instruction, and palliative modalities. In the physical therapy notes available for review, the chief complaint and daily comments sections appeared only intermittently updated.  There is only limited indication of therapeutic exercises or interventions that need formal physical therapy supervision or provision.  This patient has undergone extensive formal training and does not have cognitive or other impairments that would preclude a predominantly (but not fully) independent program.  His predominantly independent program does need periodic review, adjustment and reinforcement, particularly as new activities are introduced.  Based on the available clinical records, one visit per month for supervised therapy was and is medically indicated for these purposes.  He remains at substantial risk for suboptimal outcomes due to the chronicity, severity and nature of his underlying conditions, with or without prolonged and intensive ongoing formal physical therapy.  Notably, the enrollee has made very slow and limited progress to date despite his ongoing intensive formal therapy.  All told, one physical therapy visit per month from 5/02/16 forward was and is medically indicated for the treatment of this patient.  Therefore, a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 29-year-old male enrollee has requested reimbursement for assistant surgeon services provided on 7/17/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the Center for Medicare and Medicaid Services (CMS) provide direction relative to the typical medical necessity of assistant surgeons. The CMS has revised the list of surgical procedures which are eligible for assistant-at-surgery. For the surgery at issue, CPT code 20680, an assistant surgeon is not necessary. In addition, the study by the American College of Surgeons indicates that for CPT code 20680, an assistant at surgery is sometimes needed. Thus, the medical practice indicates that an assistant surgeon is not generally indicated for a hardware removal surgery. In addition, there was no indication in the operative report that the procedure performed was a complex procedure, or that the assistant surgeon played a significant active role in the performance of the surgery. In sum, there is no compelling rationale provided to support the medical necessity of an assistant surgeon on 7/17/15. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.