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

Summary Reviewer 3


The patient is a 62-year-old male with suspected multisystem atrophy and progressive neurologic dysfunction. He has had dysarthria, ataxia, incoordination, and possible subtle executive dysfunction.  Magnetic resonance imaging (MRI) has shown atrophy in the cerebellum, peduncles, pons, and medulla.  The records noted a hot cross bun sign suggestive of a multisystem atrophy or spinocerebellar atrophy.  On 6/28/16, progress notes indicated probable multisystem atrophy, obstructive sleep apnea, and rapid eye movement (REM) sleep behavior disorder. His provider recommended dopamine transporter single photon emission computed tomography (DaT SPECT). The patient has requested reimbursement for DaT SPECT scan of the brain performed on 9/23/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  DaT SPECT is used to identify individuals with impaired dopamine neurotransmission, and is potentially useful in the differential of patients with parkinsonian features and dementia. Possible uses include evaluation of patients with clinically uncertain parkinsonian syndromes, differentiation of essential tremor, psychogenic parkinsonism, or neuroleptic induced parkinsonism, early detection of Parkinsons disease, and differentiation of dementia with Lewy bodies from other dementias.
None of these situations apply in this patients case.  The medical evidence does not support the services at issue in this clinical setting.  Thus, DaT SPECT scan of the brain performed on 9/23/16 was not likely to have been more effective than other available modalities in this patients case.  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  
The patient is a 34-year-old male with a history of weight loss of 40 pounds, chronic diarrhea, 
and hair loss since 2017. The records indicate that the patients provider ordered a molecular-
based panel for gastrointestinal pathogens for a workup of possible underlying infectious causes 
of his constellation of symptoms. The physician reviewer found that at issue is whether CPT 
87507 - infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen 
performed on 1/2/23 was medically necessary for the evaluation of this patient. Multiple studies 
have demonstrated that molecular panel testing for gastrointestinal pathogens is associated with 
an increased detection of potential pathogens and co-infections as compared with conventional 
testing. The medical literature and several expert societies have specifically recommended 
multiplex gastrointestinal panels for patients with persistent or chronic diarrhea. Next generation 
sequencing-based  testing  of  DNA  and  RNA  has  similarly  shown  promise  in  identifying 
gastrointestinal  pathogens  undetected  by  conventional  testing.  In  this  case,  the  patient 
presented with ongoing symptoms of concern, including chronic diarrhea, weight loss, and hair 
loss, despite extensive negative testing with conventional infectious diseases diagnostics. Thus, 
the patient may have had an infectious pathogen not detected by conventional testing. Overall, 
there is sufficient support in the peer-reviewed literature and from expert societies indicating 
the efficacy of testing with a molecular-based gastrointestinal pathogen panel in this patients 
clinical setting. Therefore, CPT 87507 - infectious agent detection by nucleic acid (DNA or RNA); 
gastrointestinal pathogen performed on 1/2/23 was medically necessary for the evaluation of 
this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient has a history of osteoporosis and multiple non-traumatic fractures.  The patient is at a high risk for a major osteoporotic fracture, and pharmacological therapy is recommended.  The medical evidence supports Prolia in this clinical setting.  This patient has been treated with Fosamax, with no benefit on the patients bone mineral density.  The medical notes indicate that the patients markers of bone turnover were elevated, indicating poor absorption or increased bone turnover from rheumatoid arthritis while on Fosamax therapy.  Thus, the Prolia injection provided on 8/27/15 was likely to have been more effective than 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: Overturned

Summary Reviewer 

A 62-year-old male enrollee has requested reimbursement for a PET scan performed on 11/06/19. 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 standard differential diagnosis of an anterior mediastinal mass, whether discovered incidentally or following symptoms, is lymphoma versus metastases from a previously undiagnosed malignancy versus germ cell tumor versus thymoma. The use of PET/CT scan is valuable for multiple reasons. First, it can establish whether a lesion is highly aggressive. A lesion that has a high avidity for fluorodeoxyglucose (FDG) is more likely to be malignant, whereas a lesion that does not take up FDG could conceivably be followed without intervention. Second, the PET/CT scan will better establish whether the lesion is confined to the chest, or whether there might be distant disease. Finally, a PET/CT scan will possibly direct the provider performing the biopsy to a lesion that is more accessible than the mediastinum. The National Comprehensive Cancer Network also sees the clinical utility of PET/CT scanning in the initial work-up of suspected Hodgkin disease. In this patients case, the PET/CT scan was valuable in the management of this patient. The medical evidence supports the services at issue in this clinical setting. Therefore, the PET scan performed on 11/06/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
A 26-year-old female enrollee has requested reimbursement for myPath Melanoma test performed 
on 12/30/21. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds melanoma. The physician reviewer found 
that there is a lack of precedent for the myPath test to determine the malignant nature of the lesion 
in this patients clinical setting. As noted in the medical literature, the standard of care includes 
biopsy with removal of tissue for histopathologic examination to determine whether the lesion is 
a melanoma. Occasionally, a second opinion may be sought by a second provider for confirmation. 
Current data suggest that although the myPath Melanoma test holds promise, there is a paucity of 
data on the long-term outcomes with a lack of rigorous analysis of ambiguous lesions. The NCCN 
guidelines  referring  to  molecular  assays  for  melanoma  reports  that  these  assays  are  not 
recommended for routine use since they have not been shown to provide clinically actionable 
prognostic  information.  Furthermore,  the  impact  of  these  tests  on  diagnosis  or  treatment 
recommendations has not been established. Given these findings, the myPath Melanoma test 
performed on 12/30/21 was not likely to be more beneficial for evaluation of the patients medical 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 24-year-old male who has been diagnosed with ilieocolonic Crohnas disease. He has failed azathioprine. The patient has requested authorization and coverage for Humira Pen (adalimumab pen-injector kit 40 mg/0.4 ml) for a weekly dosage. The Health Insurer has denied this request and reported that the requested medication regimen is 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 requested medication regimen is medically necessary based on the provided documentation. Anti-tumor necrosis factor (TNF) medications such as Humira are recommended by current guidelines for Crohnas disease in patients with moderate-to-severe disease. The use of Humira 40 mg more frequently than every 14 days can be supported to prevent disease complications. In the CLASSIC-II trial, 60 of 204 open-label patients required an increase in dosing to every week. Additionally, American College of Gastroenterology guidelines for the treatment of Crohnas disease state, aThose with continued symptoms shouldahave their medication dose adjusted in order to attempt to optimize therapy.a In this case, the patient had disease previously controlled on Humira 40 mg every seven days, then active disease (corroborated by imaging) requiring when decreased to Humira 40 mg every 14 days, and then recovery of remission when increased back to Humira 40 mg every seven days. Therefore, a decrease to Humira 40 mg every 14 days, or a discontinuation of Humira (even if another alternative is immediately attempted), could result in complications of disease activity, such as disease flare, fistula, need for surgery, hospitalization, or colonic dysplasia leading to colorectal cancer. Therefore, Humira Pen (adalimumab pen-injector kit 40 mg/0.4 ml) for a weekly dosage is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 12-year-old male who has been diagnosed with idiopathic isolated growth 
hormone (GH) deficiency by a pediatric endocrinologist. The patients parent has requested 
authorization and coverage for Norditropin (somatropin) 10 mg in 1.5 ml. The physician reviewer 
found that this patient lacks any of several key diagnostic criteria for GH deficiency, such as height 
z-score below 2, growth velocity z-score below 2, delayed bone age, IGF-I z-score below 2, or 
IGFBP-3 z-score below 2.  His most recently documented height on the growth chart was within 
the normal range (approximately 15th percentile), and his predicted adult height is within the 
normal range for North American men (above 64).  He failed two standard GH provocative tests, 
but this criterion alone is insufficient to diagnose GH deficiency or to justify GH therapy. His 
pituitary gland may have been relatively small compared to his pubertal peers, yet there was no 
other anatomic abnormality observed by the radiologist. Standard care for the evaluation of 
pediatric short stature includes direct measurements of both parental heights using a calibrated, 
wall  mounted  stadiometer  whenever  possible.  This  patient  does  not  meet  sufficient  and 
generally accepted diagnostic criteria for GH deficiency. Therefore, Norditropin (somatropin) 10 
mg in 1.5 ml is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.  The physician reviewer found that the patient is a 58-year-old male who was diagnosed with an intermediate risk prostate cancer on 10/18/17. This is based on an elevated prostate-specific antigen level and a Gleason score of 3+4=7. The tumor involved four of 12 cores. The patient has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. The medical evidence supports the services at issue in this patients case. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate Cancer Assay performed on 11/13/17 was likely to have been superior over other methods of 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 

A 46-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees neck pain and bilateral upper extremity pain. The physician reviewer found that conventional radiographs are the first step in the evaluation of neck pain, particularly to diagnose post-surgical complications, degenerative disease, spinal stenosis or malalignment. After radiographs are obtained, a subset of patients may benefit from further imaging utilizing MRI or computed tomography (CT). According to the American College of Radiology appropriateness criteria for the evaluation of chronic neck pain in a patient with prior surgery and neurologic symptoms, MRI may be appropriate for further evaluation. MRI is the optimal examination for the evaluation of intervertebral discs, facet arthropathy, foraminal stenosis, nerve root compression and spinal stenosis. It can also demonstrate abnormalities present within the spinal cord, which may be the cause of neck or extremity pain. These findings are suboptimally or not at all visualized on initial radiographs, and would alter the patients management. In this case, in the setting of prior cervical fusion with neurologic symptoms, MRI is indicated for further evaluation/surgical planning. This patient already had radiographs which did not demonstrate a cause for the chronic pain. The current medical evidence supports the requested services in this clinical setting. Thus, the requested MRI of the cervical spine is medically necessary for the evaluation of this patient. Therefore, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 35-year-old female enrollee has requested authorization and coverage for brand name Qudexy XR 200 mg at the frequency of three capsules per day. The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees chronic migraines.  The physician reviewer found the request for brand name Qudexy XR 200 mg at the frequency of three capsules per day is not medically necessary for treatment of the patients medical condition. In this case, the patient presents with chronic headaches. There is a lack of documentation supporting a diagnosis of migraine. She also has history of seizures, but the records do not indicate the semiology of her seizures, response to current therapy, or previously utilized agents. The patient has marked allergies to various binders and other parts of the generic topiramate tablets. The U.S. Food and Drug Administration (FDA) has approved Qudexy dosing up to 400 mg per day for adults with generalized seizures and partial onset seizures, and studies show dosing above that does not add efficacy. The FDA recommended dose for migraine is 100 mg once per day, and in the initial clinical trials, was not effective at higher doses. As such, the requested medication dosage has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication dosage 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 54-year-old male enrollee has requested reimbursement for inpatient stay provided from 11/05/18 through 11/07/18. 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 the submitted documentation supports the services at issue in this clinical setting. The patient had exertional dizziness and some recent chest discomfort. His electrocardiogram showed evidence of prior inferior myocardial infarction. He has cardiovascular risk factors of hypertension and hyperlipidemia, and an echocardiogram showed evidence of inferior wall motion abnormalities consistent with the myocardial infarction noted on electrocardiogram. Given the evidence of prior myocardial infarction and his other risk factors, the index of suspicion for ischemic origin of symptoms is much higher, and admission for an ischemic work-up for possible acute coronary syndrome is necessary, given the known coronary artery disease. Given the patients symptoms, his cardiovascular risk factors, and the objective findings on both the electrocardiogram and echocardiogram of prior myocardial infarction and coronary artery disease, an inpatient evaluation for recurrent ischemia was medically necessary, as this is an objectively higher risk patient. Therefore, inpatient stay provided from 11/05/18 through 11/07/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The patient is a 52-year-old male with progressive neurologic symptoms over several years with sensory changes, bladder issues, erectile dysfunction, and clumsiness in association with T2 lesions in the cervical and thoracic spine and in the brain. The patient was diagnosed with multiple sclerosis (MS) and his provider has recommended treatment with Avonex. The patient has requested authorization and coverage for Avonex Pen Kit. The Health Insurer has denied this request as not medically necessary indicating that the patient has not failed treatment with three preferred alternatives such as Glatopa, Copaxone, Rebif or Gilenya.  The request for Avonex Pen Kit is not medically necessary for treatment of the patients medical condition. In this case, the patient presents with recently diagnosed MS and treatment with Avonex has been recommended. The Health Insurer has denied this request due to lack of failure with preferred formularies that include Glatopa, Copaxone, Rebif and Gilenya. The Evidence study by Panitch and colleagues showed that Rebif is more effective than Avonex. Similarly, the Transforms study showed that Gilenya is more effective than Avonex (Cohen, et al). Given that Avonex is less effective in reducing relapses than Rebif and Gilenya, Avonex is not medically necessary for treatment of the patients MS. 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: Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested authorization and coverage for inpatient care. The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees surgical procedure. The physician reviewer found that infection of a penile implant can cause complications from scarring after the penile implant is removed. Although a few studies with a small numbers of patients have shown that penile implants can be done in an outpatient setting, most providers prefer to continue preoperative antibiotics for at least 24 hours. The American Urological Associations (AUA) guideline for management of erectile dysfunction states, These antibiotics are administered before the incision is made and usually are continued for 24 to 48 hours postoperatively. The AUA best practice statement for antimicrobial prophylaxis in urologic surgery states, Although there are no [randomized controlled trials] RCTs regarding antimicrobial prophylaxis for insertion of penile prostheses, meta-analyses of mesh hernia repair 100 and orthopedic surgery 101 confirm that antimicrobial prophylaxis is beneficial when foreign material is implanted. A prolonged course of antimicrobials has been used by many practitioners following penile prosthesis insertion, but evidence from the orthopedic literature suggests that prophylaxis for 24 hours or less is adequate. In this case, there is a lack of documentation to support the medical necessity for inpatient care. Most patients who undergo penile prosthesis implantation can be discharged within 24 hours of presentation. The patient can be provided with perioperative antibiotics while on observation status without the need for inpatient stay. As such, the request for inpatient admission is not medically necessary for treatment of the patients medical condition. Therefore, the requested service is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines on osteoarthritis of the knee. The guidelines noted, aWe cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.a Kirkley and colleagues published their results on a prospective randomized trial of patients with moderate to severe knee osteoarthritis that were treated with knee arthroscopy. The authors concluded, aArthroscopic surgery for osteoarthritis of the knee provides no additional benefit to optimized physical and medical therapy.a These results were further supported by Mosely and colleagues who showed that athe outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.a In this case, the patient was being treated for knee osteoarthritis. There is no evidence of an appropriate course of non-operative treatment. There were no submitted radiology reports for knee x-rays or a knee magnetic resonance imaging (MRI). While removal of the loose body was necessary to improve mechanical symptoms to the knee, the abrasion chondroplasty for the treatment for knee osteoarthritis and degenerative joint disease is not supported by the current AAOS guidelines. Thus, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was not likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.