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

Summary Reviewer 2

A 21-year-old female enrollee has requested reimbursement for greater occipital nerve injection provided on 11/21/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that neuralgia is a type of neuropathic pain. Occipital neuralgia specifically refers to pain or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. Per the submitted documentation, this patient had evidence of occipital neuralgia on examination. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain as well as act as a diagnostic marker. According to the current data, greater occipital nerve injection on 11/21/17 was likely to have been superior over other treatment options. Based upon the information set forth above, the services at issue were 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 

A 57-year-old male enrollee has requested reimbursement for CT maxillofacial without contrast material provided on 7/29/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to support the medical necessity of the services at issue. The patient underwent resection of a calcifying epithelial odontogenic tumor in February 2019. The notes indicated that a final obturator would be fabricated in October 2019. There is no documentation to support the need for a repeat CT scan in July 2019. Patients with calcifying epithelial odontogenic tumor do require lengthy follow-up, as recurrences have been reported as late as 31 years status post surgery. In this patients case, the records do not demonstrate the need for the CT scan in July 2019. Therefore, CT maxillofacial without contract material provided on 7/29/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a two-year-old female enrollee has requested authorization and coverage for the Synagis 100 mg/mL injection. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees congenital heart disease with heterotaxy, chronic lung disease, hypoxemia on room air, pulmonary hypertension status post two diaphragmic plication procedures. The physician reviewer found that the use of Synagis in this patient is not medically necessary. The use of Synagis since 1998 has always been under strict criteria so that its use maximizes patient benefit and efficacy while not being overused. As noted above, the patients provider indicates the patient may have primary ciliary dyskinesia (PCD) which, in addition to her polysplenia, may increase the risk of developing a secondary bacterial pneumonia while co-infected with RSV. The most widely accepted guidelines for the use of Synagis are published by the American Academy of Pediatrics (AAP) Committee on Infectious Diseases and Bronchiolitis Guidelines Committee, which was last updated in 2014. These guidelines indicate there is no established role for RSV prophylaxis after 24 months of age for any patient regardless of any risk factors. The 2006 study from Thorburn and colleagues supporting an indication for Synagis in patients at high risk for pulmonary bacterial co-infection states that up to 40% of children admitted with severe RSV pulmonary disease were found to have bacterial co-infection in their lower airways. However, these children were all infants under four months of age. The article also states that in their study population, co-morbidity was not associated with high incidence of pulmonary co-infection of the lungs. Further, functional or actual asplenia has not been shown in any studies to be associated with increased hospitalization due to RSV. All told, Synagis is only indicated in children under two years of age regardless of the presence of chronic heart, lung, or immune system disease. Thus, the requested Synagis vaccine is not medically necessary for this patient. Based on the foregoing discussion, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that in this case, the patient has ankylosing spondylitis with active peripheral arthritis. She has failed methotrexate, Plaquenil and NSAIDs. In the medical literature, Callhoff and colleagues reported their meta-analysis demonstrates efficacy of tumour necrosis factor (TNF) alpha blockers versus placebo for the treatment of ankylosing spondylitis (AS) and non-radiographic axial spondyloarthritis. In this case, the patient has failed standard therapy and continues to have active disease. As such, the request for Enbrel is 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 medication is 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 


A 78-year-old male enrollee has requested reimbursement for physical therapy visits provided from 9/2/16 through 12/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post open reduction with internal fixation (ORIF) of the left femur fracture. The physician reviewer found the physical therapy visits provided from 9/2/16 through 12/23/16 were not medically necessary for treatment of the patients medical condition. As of 9/2/16, the patient was more than nine months status post injury and more than six months had elapsed after the reported hardware failure. There was no new injury or change in orthopedic status or management plan. He had chronic residual lower extremity impairment related to his injury and surgery. He was ambulating with less reliance on a cane. The patient had a unilateral lower extremity impairment and would be expected to be able to independently perform a home exercise program without requiring specialized equipment or ongoing skilled therapy oversight. A daily home exercise program would likely have best met this patients needs. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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  
The patient is a 39-year-old female with a history of large breasts, low back pain, rheumatoid 
arthritis, spinal stenosis, degenerative disease, and herniated disc. The patient underwent breast 
reduction surgery on 9/12/22. The Health Insurer has denied the service at issue as not medically 
necessary for the treatment of the patients medical condition. This denial is the subject of this 
appeal and determination. The physician reviewer found that the American Society of Plastic 
Surgeons (ASPS) guidelines state that reduction mammaplasty should be performed based on 
documentation of the severity of the symptoms of macromastia and its impact on health-related 
quality of life. The guidelines indicate that reduction mammaplasty may be performed if at least 
two of the following quality-of-life signs are present: chronic breast pain due to breast weight, 
intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, backache, 
thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial 
plexus compression syndrome secondary to the weight of the breasts being transferred to the 
shoulder strap area, headache, and congenital breast deformity. In this case, the patient has a 
history of back and neck pain. The patient also presented with rheumatoid arthritis, spinal stenosis, 
degenerative disc disease, and herniated disc. There is a lack of documentation of chronic breast 
pain  due  to  weight  of  the  breasts,  thoracic  kyphosis,  shoulder  grooving,  upper  extremity 
paresthesia, headache, or congenital breast deformity. The patient complained of intertrigo, but 
there is a lack of documentation that the patients condition was unresponsive to adequate medical 
management. Overall, there are fewer than two documented quality-of-life signs as defined by the 
ASPS. Therefore, the breast reduction surgery performed on 9/12/22 was not medically necessary 
for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 17-year-old male who was admitted on 6/22/18. The submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was admitted to the treatment center due to some oppositional behaviors as well as some anxiety symptoms. He noted daily anxiety symptoms with the majority of these symptoms related to his return home. The therapy and treatment providers were largely focused on his relationship with his family and the anxiety that this caused him. The records did not indicate that the patient expressed serious anxiety in regards to social anxiety concerns or school performance. He was not noted to have aggressive behaviors or self-harm behaviors during his stay. His risk of self-harm and danger was consistently rated as none throughout his stay. The patient denied serious depression or anhedonia during his stay. The documentation does not support failure of intensive outpatient therapy, partial hospital program therapy or cognitive behavioral therapy. 

Per the records, this patient had relational issues with his family. Initial recommendations included working on parental communication in psychotherapy. It is not clear what type of family therapy the family had engaged in on outpatient basis. Functional family therapy has proven highly successful in decreasing violence, drug abuse/use, conduct disorder and family conflict and in reducing residential treatment placements and juvenile involvement with the corrections system. Functional family therapy is typically administered on an outpatient basis, and the records indicate that this type of treatment would have been appropriate for the patient and his family on an outpatient basis. This patient also had functional impairment due to oppositional behavior, and this was one of his primary diagnoses. The evidence base regarding childrens mental health treatment has shown that treatment outside of a residential setting is effective and appropriate. In this patients case, due to his lack of severe symptoms and dangerous behaviors, less restrictive care was appropriate especially as related to family therapy as well as cognitive behavioral therapy for his anxiety symptoms. Due to the patients overall mild symptoms and lack of evidence to support failure of less restrictive treatments, the services at issue were not medically indicated. Thus, mental health residential treatment provided from 7/11/18 through 8/06/18 were not medically necessary 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  
The patient is a 47-year-old male with a history of lumbar pain and lumbar radiculopathy. The 
provider has recommended a right laminotomy (hemilaminectomy), with decompression of nerve 
root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral 
disc; one interspace, lumbar. The Health Insurer has denied the requested services as not medically 
necessary for the treatment of the patients medical condition. This denial is the subject of this 
appeal and determination. The physician reviewer found that this patient has a history of lumbar 
pain and lumbar radiculopathy. According to Zaina and colleagues, there is insufficient evidence 
to conclude whether surgical treatment or a conservative approach is better for patients with lumbar 
spinal stenosis. Moreover, the patients exam findings from 3/8/23 were relatively normal with no 
evidence  of  any  neurological  deficits,  which  was  unchanged  throughout  the  follow-up 
examinations. The patients pain decreased from the 3/8/23 exam to the 3/29/23 exam. In addition, 
the  records  provided  for  review  fail  to  document  a  trial  and  failure  of  recent,  reasonable, 
comprehensive, less invasive conservative care measures. The records provided fail to document 
the timing of the conservative treatment attempted by the patient, as well as any benefits from 
those treatments. Overall, there are limited large-scale, long-term studies showing the safety and 
efficacy of the requested surgery in this clinical setting. Given these findings, the requested right 
laminotomy  (hemilaminectomy),  with  decompression  of  nerve  root(s),  including  partial 
facetectomy,  foraminotomy  and/or  excision  of  herniated  intervertebral  disc;  one  interspace, 
lumbar are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 52-year-old male enrollee has requested reimbursement for knee orthosis provided on 12/15/17. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollee, who was diagnosed with complex tear of the medial meniscus. The physician reviewer found that the submitted documentation does not demonstrate the medical necessity of the equipment at issue. In this patients case, the records document a medial meniscal tear and contusion of the medial compartment. The provider recommended arthroscopic partial medial meniscectomy and a valgus off-loader knee orthosis. The literature does not support the use of off-loader braces after medial meniscectomy. The current medical evidence does not support the equipment at issue in this clinical setting. Dammerer and colleagues concluded that 12 weeks of compartment-unloading therapy, with either a knee brace or wedge insoles, is ineffective with regard to clinical outcome after arthroscopic partial meniscectomy. Thus, knee orthosis provided on 12/15/17 was not medically necessary for the treatment of this patient. Therefore, the equipment at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 29-year-old male enrollee has requested authorization and coverage for suction assisted lipectomy of the trunk. 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 has grade I gynecomastia with tenderness. Surgery for removal of the small symptomatic breast mass has been approved by the Health Insurer. Authorization is requested for liposuction of the chest area for removal of fatty tissue. Any surrounding fatty tissue is not gynecomastia but pseudogynecomastia, and results in no pain or tenderness. Arya and colleagues noted that True gynecomastia refers to enlarged glandular tissue rather than deposition of fat tissue. Enlargement of breast due to deposition of fat in the breast area is known as pseudogynecomastia. Per the authors, The aims of surgery are: (a) To eliminate painful breast tissue; and (b) To restore the patients chest to acceptable cosmetic shape. The most commonly used technique is subcutaneous mastectomy that involves direct resection of the glandular tissue using a periareolar or transareolar approach, with or without liposuction. Bellini and colleagues stated, In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision. Liposuction of the surrounding fat tissue would be for the treatment of pseudogynecomastia and not for the treatment of gynecomastia. Liposuction would be for the purpose of improving the appearance of the chest. Liposuction of the fatty tissue on the chest would be cosmetic surgery and not medically necessary. Therefore, the requested suction-assisted lipectomy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 73-year-old male enrollee has requested reimbursement for targeted genomic sequence analysis (81445). The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has metastatic non-small cell lung cancer. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care for patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. This patient has progression of disease after prior therapy including with immunotherapy. The medical evidence supports the services at issue in this clinical setting. Therefore, targeted genomic sequence analysis (81445) performed on 4/17/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. 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 the current medical evidence supports the requested services in this case. This patient has obstructive sleep apnea and has Friedman 3 tongue position. A drug induced sleep endoscopy showed no concentric collapse at velum. The patient has not been able to tolerate the continuous positive airway pressure (CPAP) device. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. This patient is a candidate for the Inspire device given his body mass index is less than 32, he has apnea-hypopnea index (AHI) of 21.2, and has no concentric collapse at the velum. In sum, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 61-year-old female who presented to her provider on 7/28/20. The patient has requested authorization and coverage for bilateral eyelid surgery, with dacryocystorhinostomy and probing of nasolacrimal duct, with or without irrigation, with insertion of tube or stent. 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 Dacryocystorhinostomy is medically necessary in this case due to the symptoms of tearing and acquired stenosis of the lacrimal sac on examination. Upper eyelid ptosis repair is medically necessary in this case based on the functional complaints, photographs, and physical examination. The patient has well-documented functional complaints related to the eyelids drooping. The records document ptosis as evidenced by physical examination and photographs. The visual fields, history and photographs are compelling evidence of functional disability. There is sufficient support for the requested services in this clinical setting. Therefore, bilateral eyelid surgery, with dacryocystorhinostomy and probing of nasolacrimal duct, with or without irrigation, with insertion of tube or stent is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 35-year-old male enrollee has requested authorization and coverage for Actemra 400 mg/ 20 ml vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees anti-neutrophil cytoplasmic autoantibodies (ANCA) associated crescentic and immune complex glomerulonephritis. The physician reviewer found according to the documentation submitted for review, the patient has tried all conventional treatments for his ANCA associated crescentic and immune complex glomerulonephritis condition. His renal function has deteriorated with his creatinine on 3/15/15 at 4.0 with potassium of 5.2. Given his present condition and his previous response to medical therapies, at this time Actemra is 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 medication is 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 


A 49-year-old female enrollee has requested authorization and coverage for endoluminal ablation. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins. The physician reviewer found that the documentation supports the medical necessity of the requested endoluminal ablation. The patient is experiencing significant worsening edema in the right leg that limits her ability to perform activities of daily living despite conservative treatments including the use of medical grade compression stockings. In addition, the Duplex findings are remarkable with respect to the large size of the involved vein and the extensiveness of the reflux. Given these findings, the treatment plan is both appropriate and medically necessary. Based on the foregoing discussion, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.