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

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for a blood test performed on 11/24/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the records noted that the patient previously tested positive for Helicobacter pylori. However, the modality of testing was not specified. Consistent with standard of care, Braden noted 13C urea breath test or the stool antigen test can be used for non-invasive screening for Helicobacter pylori in a test and treat strategy in younger patients presenting with dyspepsia without alarm symptoms without the need for endoscopic prelude to therapy or re-treatment. Serologic testing, as in this patients case, was not recommended as the study of choice or standard of care. The immunoglobulin G (IgG) antibody assayed in this case offers little assistance in distinguishing between active disease and previous exposure. Further, antibodies to Helicobacter pylori can remain elevated for a long time even after treatment, potentially increasing the number of false-positive results. In this patients case, the records do not specify whether she received treatment upon Helicobacter pylori detection in Taiwan, or whether it was her desire to be retested to assess efficacy of past eradication efforts. Serologic testing for re-documentation of a previously positive Helicobacter pylori status was not likely to have been more beneficial in achieving positive outcome than standard testing with detection of active infection with stool antigen or urea breath assays. In sum, the blood test performed on 11/24/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 32-year-old female enrollee has requested reimbursement for targeted genomic sequence analysis panel performed on 7/13/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees thyroid nodule.The physician reviewer found that the while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. The relatively new development of molecular techniques and the identification of genetic alterations associated with different follicular cell-derived cancers in the thyroid have led to the introduction of several commercially available tests. Among the new molecular tests is targeted genomic sequence analysis panel testing. This testing allows simultaneous testing for multiple mutations with high accuracy and sensitivity, requires a small amount of DNA and can be performed in a variety of thyroid tissue and fine-needle aspiration samples, and provides quantitative assessment of mutant alleles. The high sensitivity and specificity of targeted genomic sequence analysis panel helps to identify which neoplasms are more likely to be malignant, while ruling out the benign neoplasms, thereby decreasing the risk of unnecessary surgery. There is sufficient support for the services at issue in this clinical setting. All told, targeted genomic sequence analysis panel performed on 7/13/17 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Optune therapy (E0766) from 6/19/18 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 glioblastoma multiforme. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. Optune (Novo-TTF) is a novel portable medical device which is worn on the scalp and generates low-intensity alternating electric fields. This was initially approved for use in the treatment of glioblastoma in 2011. Stupp and colleagues demonstrated that Optune is less toxic than Temodar, with the same overall survival statistics. The advantage of the combination of Optune with Temodar was reaffirmed in the review by Taphoorn and colleagues. All told, Optune therapy (E0766) from 6/19/18 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 14-year-old male with a history of short stature. He presented to his endocrinologist on 7/06/20. The physician reviewer found that this patient has a history of short stature. He is not growth hormone deficient as shown by the growth hormone stimulation test done in 5/28/20. He has a strong family history of constitutional delay. On 7/06/20, he was examined and was found to be in puberty and he mostly likely will continue to grow even without growth hormone therapy. Growth hormone therapy is not medically necessary in his case as his clinical indication does not fit into the category of idiopathic short stature (ISS). His final predicted height is 5a5.5a, which is above the cut off of treatment of ISS. Therefore, Humatrope is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 49-year-old male enrollee has requested reimbursement for short-term rehabilitation services provided on 6/3/16, 6/16/16, 8/12/16, 9/9/16, 9/30/16 and 11/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low back pain. The physician reviewer found that the short-term rehabilitation consisting of the EMS (CPT 97014) services provided on 6/3/16, 6/16/16, 8/12/16, 9/9/16, 9/30/16 and 11/23/16 were medically necessary for treatment of the patients medical condition. The EMS was clinically indicated for treatment of the patients neck, low back, and hip pain. However, the remaining short term rehabilitation services provided on 6/3/16, 6/16/16, 8/12/16, 9/9/16, 9/30/16 and 11/23/16 were not medically necessary. There is a lack of functional deficit documentation to support extraspinal manipulation and intersegmental traction. In general, mechanical traction is recommended for patients with radiculopathy diagnosis in conjunction with other treatment such as exercises, if there are documented failure of other evidence-based therapeutic procedures to resolve symptoms 18 after three weeks. In this case, there is a lack of documentation demonstrating documented failure of such treatments. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for photodynamic therapy (CPT 96567) and aminolevulinic acid HCL for topical administration, 20% single unit dose (J7308) performed on 6/20/17 and 6/28/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee who has a history of skin cancer. The physician reviewer found that the documentation provided supports a portion of the services at issue in this clinical setting. This patient has a history of multiple non-melanoma skin cancers and actinic keratosis but has failed treatment with 5-fluorouracil. The use of photodynamic therapy with aminolevulinic acid of non-hypertrophic actinic keratoses involving the scalp and face have been shown to be an effective therapy. This patient had treatment of the face on the first session and his left arm and left hand were treated during the second session.  As there is support in the medical literature for the use of photodynamic therapy with aminolevulinic acid for the treatment on actinic keratosis of the face and scalp, a portion of the services at issue was medically necessary for treatment of this patient.  Photodynamic therapy (CPT 96567) and aminolevulinic acid HCL for topical administration, 20% single unit dosage form (J7308) of the face were medically necessary. However, photodynamic therapy (CPT 96567) and aminolevulinic acid HCL for topical administration, 20% single unit dosage form (J7308) of the left arm and left hand were not medically necessary for treating this patients medical condition. As such, a portion of the services at issue was medically necessary. Therefore, for the reasons stated above, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for itraconazole capsules 100 mg, two (2) twice per day one week per month for three months; 28 capsules every 30 days for three (3) months. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees onychomycosis.  The physician reviewer found that the Itraconazole is covered for patients with diabetes or peripheral vascular disease with a positive fungal culture or for patients who have documented pain with a positive fungal culture. Although the patient is not a diabetic and does not have peripheral vascular disease, there is documentation that the nails are increasingly painful and there is a positive fungal culture which supports an indication for this therapy. Accordingly, the requested itraconazole capsules 100 mg, two (2) twice per day one week per month for three months; 28 capsules every 30 days for three (3) months is medically necessary for the treatment of this patients condition.Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 54-year-old female who presented to her provider on 8/31/20. The records noted chronic migraines and headaches. The patient has a history of sagittal venous thrombosis. The patient requested authorization and coverage for Botox and Xeomin injections (64612, 64646, 64647 and 64644). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that Cervical dystonia (CD) is a movement disorder clinically characterized by involuntary contractions of cervical muscles, which cause abnormal head movements and postures, often associated with head tremor and chronic pain. Classifications of CD include torticollis (turning or rotation of the head towards one side); laterocollis (tilting of the head towards one side); anterocollis (head and neck flexion), and retrocollis (head and neck extension) or a combination of these movements. Per the 2016 American Academy of Neurology (AAN) practice guidelines, botulinum toxin is accepted as first-line treatment for CD. OnabotulinumtoxinA (OnaBoNT-A/Botox) and incobotulinumtoxinA (incoBoNT-A/Xeomin) are two preparations of botulinum toxin approved by the U.S. Food and Drug Administration. In this case, the patient has cervical dystonia with spasmodic torticollis.  Per the AAN practice guidelines, botulinum toxin (Botox and Xeomin) are accepted as first-line treatment for cervical dystonia. Therefore, Botox and Xeomin injections (64612, 64646, 64647 and 64644) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 61-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 3/29/19. 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 National Comprehensive Cancer Network recommends testing with Oncotype DX Prostate Cancer Assay post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network 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. This patient has a low risk prostate cancer and met this criteria. Therefore, Oncotype DX Prostate Cancer Assay performed on 3/29/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 35-year-old female enrollee has requested authorization and coverage for CPT codes 64635-50 and 64636-50. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees sacroiliac joint dysfunction. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has a history of severe low back and lower extremity pain.  She underwent various modalities of treatments, without success.  Diagnostic sacroiliac joint blocks provided her with excellent pain relief.  This patients symptomatology and diagnostic assessments meet the criteria for radiofrequency neurotomy.  The current medical evidence supports radiofrequency neurotomy in managing sacroiliac joint pain confirmed by diagnostic blocks.  All told, the requested CPT codes 64635-50 and 64636-50 are medically indicated for the treatment of this patient.  Therefore, 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 1

A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. 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 patientas condition is not controlled by the standard steroid injections treatment or methotrexate. In the past, his hair loss had progressed to the totalis pattern. For challenging patterns of alopecia areata, oral tofacitinib is an excellent choice for the next step on the treatment ladder. There is a significant volume of peer-reviewed literature demonstrating efficacy. In this
patientas case, Xeljanz is likely to be more effective than any other standard therapy. Other untried, non-standard therapeutic options are systemic and fraught with cumulative toxicities and other dangerous side effects. Tofacitinib is a well-known and commonly used therapeutic for alopecia areata. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

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 placental thrombosis due to maternal clotting abnormality has been proposed as a cause of first trimester loss and stillbirth. According to the American College of Obstetricians and Gynecologists (ACOG), prospective cohort studies have found no association between inherited thrombophilias and fetal loss. More specifically, because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, screening for MTHFR mutation analyses is not recommended (Robertson, et al). For these reasons, 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: Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for services at Provo Canyon School in Utah from 8/31/14 through 12/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (Hales, et al). The standard of care for treatment of children and adolescents should be in the least restrictive setting as possible in order to maintain and foster natural supports (Winters, et al). It is further recommended that children should be treated in the setting that is least restrictive and disruptive to their lives. Inpatient or residential treatment is indicated only in emergencies or for children who have not responded to efforts at outpatient treatment. In a study by Barth and colleagues, children in intensive in-home therapy were more likely to live with family, make progress in school, not have trouble with the law, and have better placement permanence than youth who were treated in residential treatment facilities. In this patients case, she made significant progress regarding her behaviors and her ability to control her distress. By 8/1/14, her thoughts of self-harm decreased since her initial admission in May 2014.  The improvement in her symptoms indicated that she could have been managed in a less restrictive setting. While she had continued symptoms of anxiety and periods of emotionality, she was not displaying any significant or severe behavioral problems during the disputed period. She was noted to be cooperative in therapy and was insightful into her need for treatment and her behaviors.  The records indicate that the patient needed more treatment to further improve her social functioning, anxiety, family relationships, and self-harm thoughts. However, the submitted documentation indicates that this patient no longer needed the restrictiveness of a residential psychiatric treatment facility as she had stabilized enough over the previous three months of residential care to transition to a less restrictive setting by 8/31/14. The medical evidence support residential treatment when used for acute stabilization. However, there is a lack of evidenced based reviews to support residential treatment for long term care as in this patients case. All told, the services at Provo Canyon School in Utah from 8/31/14 through 12/19/14 were not medically necessary for 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 


A 55-year-old male enrollee has requested authorization and coverage for Lantus Solostar. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes and hyperlipidemia.   The physician reviewer found that Lantus was the first once-daily, long-acting insulin analog to be introduced more than 10 years ago and is specifically designed to provide basal insulin requirements (Hilgenfeld, et al). Manufacturers of insulin products for diabetes therapy have long sought ways to modify the absorption rate of exogenously administered insulins in an effort to better reproduce the naturally occurring pharmacokinetics of endogenous insulin secretion (Heise and Mathieu). Recent studies have demonstrated that newer basal insulins, such as Levemir have similar efficacy to that of Lantus (Dailey, et al). This patients records do not document that an adequate trial of Levemir has been performed or that the patient has a contraindication to this formulation. Thus, the requested Lantus Solostar is not supported as medically necessary for treatment of this patients type 2 diabetes. Based on these findings, 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 1

The patient is a 24-year-old female with a history of both palmar and plantar severe hyperhidrosis.  Her condition has been refractory to medical therapy.  The patient has had thorascopic sympathectomy which resolved the palmar hyperhidrosis, but she has persistent plantar symptomatology that has caused significant lifestyle and medical issues.  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. The medical evidence supports the services at issue in this clinical setting.  This patient has failed conservative medical therapy.  The requested procedure has been discussed in the peer-reviewed literature and has been shown to have efficacy for the treatment of this patients condition.  All told, sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17 was and is likely to be more effective than other 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.