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

Summary Reviewer 1


A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this clinical setting.  The medical records document paroxysmal atrial fibrillation and a prior stroke with no documented significant bleeding complications on anticoagulation.  In this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk, discontinuing anticoagulation while accepting an increased thromboembolic risk or percutaneous left atrial appendage exclusion using a Watchman device.  The Watchman device has been demonstrated in one trial to be non-inferior compared with warfarin.  However, device placement has a high rate of significant complications due to pericardial effusion and procedural stroke related to thromboembolism or air embolization.  The Watchman device is not likely to be of greater benefit than other treatment options, especially in patients who are tolerating anticoagulation without significant bleeding side effects.  Based upon the information set forth above, the requested services are 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 patient is a 10-year-old female with a history of Pitt-Hopkins syndrome and associated motor 
planning difficulties, possible weakness in the oral area, and receptive and expressive language 
delays. The provider has recommended that the patient continue to receive individual speech 
and language therapy sessions twice a week for 60-minute sessions. The Health Insurer has 
denied the requested services as not medically necessary for treatment of the patients medical 
condition. The physician reviewer found that Pitt-Hopkins Syndrome is a genetic condition that 
presents as a neurodevelopmental disorder caused by monoallelic mutation or deletion in the 
transcription factor 4 (TCF4) gene (Kim, et al.). The patients underlying genetic defect does not 
preclude neuroplasticity while the brain is still undergoing neurodevelopment during the first 
two decades of life. In this developmental timeframe, speech therapy has been shown to impact 
ongoing  neurodevelopment.  Given  this  patients  motor  planning  disabilities,  oromotor 
weakness, and receptive and expressive language delays, the patients treatment will continue 
to consist of oral motor exercises, tactile-kinesthetic associative mapping of speech sounds in 
syllables and words, and a program of building receptive and expressive language. Furthermore, 
the patients previous speech and language therapy sessions twice a week for 60-minute sessions 
have produced positive results for the patient. For these reasons, the requested speech therapy 
sessions are medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for CPT code 95810 performed on 1/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In this case, the patient presented with complaints of snoring. She had previously undergone a home sleep test in November 2017 which was non-diagnostic for obstructive sleep apnea. It has long been the standard of care for patients suspected of having obstructive sleep apnea to be referred for attended polysomnography in the setting of a negative home sleep test. The subsequent polysomnography revealed a diagnosis of obstructive sleep apnea, with the patient being found to have a RDI of 8.7. An RDI of 5.0 or greater is positive for obstructive sleep apnea based on current diagnostic standards. A home sleep test cannot detect respiratory effort-related arousal (used in calculating RDI) and may otherwise underestimate the degree of sleep related breathing disorder. In this case, performance of polysomnography would have been appropriate to rule in/out a diagnosis of obstructive sleep apnea in this setting of a negative home sleep testing. Therefore, CPT code 95810 performed on 1/05/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 29-year-old female enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing for methylenetetrahydrofolate reductase (MTHFR) and molecular pathology testing performed on 5/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for recurrent pregnancy loss. The physician reviewer found that in this case the patient presents with a history of third trimester loss. An appropriate work-up needs to address the potential etiologies of full term unexplained stillbirths including genetic studies, thyroid studies and antiphospholipid antibodies (APLAS). In this case, there does not appear to be a pathology report that suggests that the placenta was infected or that fetus was severely growth restricted, or that the placenta exhibited signs of chronic ischemic, thrombotic abruption, or chronic abruption like event. According to the current American College of Obstetricians and Gynecologists (ACOG) recommendations testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Accordingly, the PCR testing for MTHFR and molecular pathology testing performed on 5/26/16 was not 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 27-year-old female. Notes dated 7/20/22 reported that biopsies and clinical 
presentation were consistent with moderate-severe Crohns disease, with inadequate response to 
budesonide. The physician reviewer found that the submitted documentation supports the medical 
necessity of the requested medication. Large, high-quality, randomized controlled trials have 
demonstrated the safety and efficacy for induction and maintenance of remission in patients with 
moderate-severe Crohn's disease using Skyrizi. D'Haens and colleagues note that risankizumab is 
effective and well tolerated as induction therapy in patients with moderately to severely active 
Crohn's  disease.  Ferrante  and  colleagues  report  that  long-term  maintenance  treatment  with 
subcutaneous risankizumab is well tolerated by patients with Crohn's disease, with no new safety 
signals. With Skyrizi, patients achieve high rates of clinical and endoscopic remission.  The 
American College of Gastroenterology (ACG) guidelines do not recommend alternatives such as 
budesonide, which this patient has tried and failed, as chronic therapy. In this case, the records 
document that the patient has had improvement with Skyrizi, and a discontinuation may result in 
recurrent symptoms and complications such as disease flare, hospitalization, need for surgery, 
fistula, and stricture. Continuation of therapy after intravenous induction doses would warrant 
subcutaneous dosing. Given that current medical literature supports the use of Skyrizi in this 
clinical setting, the requested medication is medically indicated. Therefore, Skyrizi 150 mg is 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 24-year-old female who underwent bilateral thorascopic sympathectomy for severe palmar hyperhidrosis in 2013.  This intervention helped her palmar, but not plantar, symptoms.  The plantar sweating interferes with her social and functional life, and represents a danged as she slips and falls frequently due to her wet feet.  Prior attempts to control her symptoms with conservative measures such as Drysol and Robinul Forte have failed. The patient has requested reimbursement and prospective authorization and coverage for sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17. The Health Insurer has denied this request and reported that the services at issue were and are investigational for the treatment of this patient. Plantar hyperhidrosis is relatively uncommon in comparison with palmar hyperhidrosis.  Per the medical evidence, plantar hyperhidrosis responds to sympathectomy.  There are several reports regarding lumbar sympathectomy having a good effect on symptoms.  All told, sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17 was and is likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
 
A 55-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that transcranial Magnetic Stimulation (TMS) is a noninvasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is approved by the United States Food and Drug Administration. TMS tends to be very well tolerated with fewer barriers than electroconvulsive therapy. Further, subsequent to the FDA recommendation, the American Psychiatric Association (APA), investigated this treatment and the available literature.  The outcome of the investigation in 2010 was APA endorsement of TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  The standard of care does not require multiple medication trials and pharmacologic augmentation prior to TMS therapy. Likewise, even though this patient more than likely meets criteria for severe depression as he has most of the symptoms. He has an observable disability, in his case, the inability to work. The treatment is not limited to a certain specifying characterization of the depressive episode.  The APAs endorsement for TMS therapy is a compelling determination supporting its use for treatment of major depressive disorder. 
In this particular case, the patients affective illness is not disputed.  He has pursued, but not exhausted, other standard therapies used to combat depression.  Thus, common alternatives may also be considered medically necessary as defined by the Health Insurer.  However, considering the medical records, endorsement from the APA and the expanding peer reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice that is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  As such, TMS is medically necessary for the treatment of this patients behavioral health condition. 
Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found non-invasive prenatal testing uses cell-free fetal DNA from the plasma of pregnant women to detect trisomy 13, 18 or 21 (Sparks, et al.). The American College of Obstetrics and Gynecology has recommended that women, regardless of maternal age, be offered prenatal assessment for aneuploidy either by screening or invasive prenatal testing. Cell-free DNA is now another option that can be used as a primary screening test in women at an increased risk of aneuploidy. Increased risk women include maternal age 35 years or older with fetal findings indicating an increased risk of aneuploidy. In this case, the patient was at an increased risk of aneuploidy, given the fetal ultrasound findings indicating an increased risk of trisomy. The patients anatomic screen demonstrated two soft signs, and for this reason the cell-free DNA screening was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition. Based upon the information set forth above, the testing 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: Experimental
Decision: Overturned

Summary Reviewer 3
A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. 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 this patient has facial angiofibromas, which is a finding in his genetic disorder called tuberous sclerosis complex. These angiofibroma are at risk of bleeding and growing. Treatment options have mainly consistent of laser ablation, which at times could mean increased risks due to general anesthesia due to the sheer number of lesions and scarring. This medication is an accepted treatment option for facial angiofibromas, as evidenced by the medical literature. Thus, sirolimus cream is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

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 Prometheus Anser IFX diagnostic testing performed on 7/7/14 was likely to be more effective for this patient than other available treatment options. The patient was complaining of body aches and fatigue and had been evaluated by rheumatology which was negative. Thus, her treating provider ordered testing to check for adalimumab levels and antibodies to adalimumab. The dose interval subsequently decreased to every three weeks. Therefore, Prometheus Anser IFX testing was appropriate for the management of the patients Crohns disease in order to optimize her therapy and to maintain remission without drug toxicity. 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 38-year-old female has requested reimbursement for fecal calprotectin testing performed on 11/22/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative pan-colitis. The physician reviewer found that Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in tissue samples, body fluids, and stools, making it a potentially valuable marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. An additional potential role of fecal calprotectin is in the monitoring of patients with colitis to predict whether they are going to have a disease flare and to distinguish in symptomatic patients whether the symptoms are due to inflammation or to functional disease. In this patients case, she had a recent colonoscopy showing endoscopic healing, and she had no complaints relative to her colitis. There is a lack of support for the services at issue in this setting. Thus, fecal calprotectin testing performed on 11/22/17 was not likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 16-year-old male with a history of mood dysregulation disorder, attention deficit/hyperactivity disorder, cannabis use disorder, and hallucinogen use disorder. The patient was admitted to an intensive outpatient program on 12/15/17 due to angry outbursts, substance use, and emotional dysregulation. The patient was treated with individual, family, and group psychotherapy along with medication management. The Health Insurer has denied reimbursement and prospective authorization and coverage for mental health intensive outpatient treatment provided from 2/17/18 forward. Per the Health Insurer, the services at issue were not and are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The Child and Adolescent Level of Care Utilization System (CALOCUS) is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient had chronic passive suicidal ideation with no intention or plan. There is no documentation of prior suicide attempts. With regards to functional status, the records support a score of 3. The patient has conflicted relationships with his peers and family. During the intensive outpatient program treatment, the patient has had problems focusing when asked to complete assignments. He will resist encouragements to complete assignments. He has chronic severe deficits in interpersonal relationships, and he has severe deficits in his ability to engage in socially constructive activities. In terms of comorbidity, the records support a score of 3. The patient has comorbidities of mood dysregulation disorder, attention deficit/hyperactivity disorder, cannabis use disorder, and hallucinogen use disorder. With regards to environmental stress of the recovery environment, the records support a score of 3. The patient has chronic interpersonal conflicts with his parents. He has angry outbursts at home. In terms of environment support, the records support a score of 3. With regards to resiliency, the records support a score of 3. The patient has made minor improvements during his intensive outpatient program treatment, such as remaining sober. However, he continues to be irritable, angry, easily agitated, and resistant to treatment. In terms of acceptance and engagement, the records support a score of 3. On many occasions, the patient has not cooperated with treatment. He is easily agitated and frequently irritable. Thus, the records support a composite score of 20. Based on these criteria, the patient meets criteria for continued intensive outpatient program treatment. Therefore, mental health intensive outpatient treatment provided from 2/17/18 forward was and is medically necessary for the treatment of this patient. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 21-year-old male with gastroesophageal reflux disease (GERD). An esophagogastroduodenoscopy (EGD) dated 6/2/17 showed localized irregularity of the mucosa in the Z-line and gastroesophageal junction and patchy erythema in the gastric fundus, body, and antrum. The digestive disease patient history questionnaire dated, 8/8/17 notes the patient has gastric reflux symptoms. Esophagogastroduodenoscopies showed antral erythema and Z-line irregularity without esophagitis or Barretts. A Bravo pH test on 8/18/17 was normal. The patient has requested authorization and coverage for the esophageal sphincter augmentation device (CPT code 43284). The Health Insurer has denied this request as investigational. The request for esophageal sphincter augmentation device (CPT code 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of randomized controlled trials with long-term follow-up demonstrating that the esophageal sphincter augmentation device is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies remains to be determined (Sheu and Rattner). In addition, adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval, (Bauer, et al). The currently available peer-reviewed literature does not definitively support the conclusion that the esophageal sphincter augmentation device is likely to be more beneficial than standard treatment. The American College of Gastroenterology guidelines for the management of reflux disease states that more evidence is needed before the esophageal sphincter augmentation device can be recommended (Katz, et al).  For these reasons, the esophageal sphincter augmentation device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.