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

Summary Reviewer  
 
The patient is a 62-year-old male with a history of an elevated prostate specific antigen (PSA) of 
12.7 ng/mL and prostate cancer. The patient was recommended to undergo combined androgen 
deprivation therapy with radiation therapy directed at the prostate, pelvic lymph nodes, and 
metastatic disease within the bone. The physician reviewer found that this patient has a history 
of Gleason score 8 prostate cancer. The patients provider has recommended treatment with 
proton beam radiation therapy to treat the prostate, pelvic lymph nodes, and adjacent bony 
metastases. The patients presentation is consistent with oligometastatic disease, which is 
metastatic disease but in few a localized sites within the body. Currently, there are data in the 
medical literature supporting aggressively treating the oligometastatic sites with improved 
disease outcomes. Per the National Comprehensive Cancer Network (NCCN) guidelines, the 
utilization of proton beam as the treatment modality is not supported for the routine treatment 
of patients with prostate cancer. Proton beam has unique properties compared standard photon 
or  x-ray  beam  in  its  ability  to  deposit  radiation  dose.  However,  there  is  a  lack  of  data 
demonstrating that the use of proton beam will result in any significant improvement in clinical 
outcome (Royce and Efstathiou). Thus, proton therapy is strongly indicated in settings where 
severe toxicities would result if normal tissue constraints cannot be met by photon beam. 
Additional studies have not demonstrated clinically significant improvements in survival or 
normal tissue toxicities over photon beam when treating prostate cancer (Royce, et al.). In 
addition, proton therapy may be appropriate in cases of unusual anatomy or in cases of re-
irradiation  of  adjacent  tissues.  On  review  of  this  patients  records,  there  is  a  lack  of 
documentation of unusual anatomy or previous radiation in the target area. Given these findings, 
the requested proton beam radiation therapy is not medically necessary for treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential treatment program services provided from 7/26/14 through 5/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential treatment center services provided from 7/26/14 through 9/26/14 were medically necessary for treatment of the patients medical condition, but not thereafter. RTC level of care was initially indicated due to the patients emotional deregulations, depression, passive suicidal ideation and poor insight. However, by 9/26/14 the patient was documented to be upbeat and demonstrated a positive response to individual therapy. The patient was not a danger to herself or others. She was medically and psychiatrically stable. After the initial two months of treatment, she could have been stepped down to a lower level of care such as partial hospitalization or intensive outpatient services. Moreover, treatment closer to home would have allowed her develop her relationship with her family and to work with her therapist. As such, residential treatment center services provided from 7/26/14 through 9/26/14 were medically necessary, after which she could have been treated at lower level of care. 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 70-year-old male enrollee has requested reimbursement for service code 97139, unlisted therapeutic procedure, performed on 4/20/20. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue. The services at issue were not likely to have been superior over standard therapy of physical therapy, epidural steroid injections, modification of the activity that may exacerbate the pain, and medication management. A review of the literature does not reveal sufficient evidence regarding the effectiveness of this procedure for this patientas condition. Therefore, the unlisted therapeutic procedure provided on 4/20/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 49-year-old male who presented to his provider on 4/05/22. The records noted 
erectile dysfunction and Peyronies disease. Digital rectal examination revealed a 30 g anodular 
prostate. On 4/06/22, the records noted that the patients medications included finasteride. The 
patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the 
pelvis. The physician reviewer found that the submitted documentation supports the medical 
necessity of the requested services in this clinical setting. In this patients case, MRI is indicated 
based on the elevated PSA, age of the patient, and previous history of finasteride. Increasingly, 
as supported by National Comprehensive Cancer Network (NCCN) guidelines, multiparametric 
prostate MRI and serum biomarker testing are being used to assist in this initial assessment of an 
elevated PSA as an alternative to routine initial transrectal ultrasound-guided biopsy. Prostate 
MRI with MRI-directed biopsy is increasingly regarded as a valuable tool for refining risk status 
for clinically meaningful prostate cancer. Multiparametric MRI-directed biopsy is more sensitive 
than  systematic  transrectal  ultrasound-guided  techniques  when  used  alone  for  detecting 
clinically significant prostate cancers and, importantly, for reducing the number of insignificant 
cancers diagnosed. Therefore, the requested MRI of the pelvis is medically necessary for the 
evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 64-year-old male with hypogonadism manifested with low libido and low energy levels. His total testosterone was 208 in 2011. He was treated with Testopel pellets on 1/21/16 and 5/26/16. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The Testopel implants provided on 1/21/16 and 5/26/16 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Testopel is an alternative approved method of treating hypogonadism in an older male. It offers the advantages of maintaining a steady level of testosterone over many months. In addition, it eliminates the need for repeat daily or weekly or monthly dosing and is not dependent upon varying factor as to absorption like with testosterone gels and creams. Based on the clinical documentation submitted for review, the services at issue were 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 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 
The patient is a 52-year-old female who has a history of chronic groin pain. In 2013, she had a repair of a right inguinal hernia. The patient has requested reimbursement for CT of the pelvis (72193) performed on 5/05/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination.  The physician reviewer found that the Health Insureras denial noted that the patientas ahip paina should have been managed conservatively for six weeks, and that plain x-rays had not been obtained. The Health Insurer used the requirements for musculoskeletal hip pain, rather than groin pain. When considering the possibility of an inguinal hernia, the referring practitioner has multiple modalities at his disposal. The first is a physical examination. Inguinal hernias, however, can be difficult to detect, especially in heavy individuals. After a physical examination, and generally before any contemplated surgery, another confirmatory imaging test is often performed. One possibility is ultrasound, although sonography is largely operator dependent. As noted by Piga, aWe found that ultrasound had the highest sensitivity and specificity. However, it must be taken into consideration that performance is highly dependent on the operatoras level of expertise.a An ultrasound study will also not necessarily detect a sliding or intermittent hernia. Another possibility, and often the preferred imaging test, is a CT scan of the area. The advantage of a CT scan is that it is not at all operator dependent, and that it will not only detect a hernia, but it will also establish the nature of the hernia. In addition, a CT scan will differentiate between an inguinal hernia, a femoral hernia, and an obturator hernia. Garvey noted, aThis prospective non-contrast CT study of patients with undiagnosed chronic groin pain detected the majority of occult hernias requiring surgical intervention. These results suggest that CT can be a useful adjunct to the evaluation of patients presenting with chronic undiagnosed groin pain, but that experienced clinical judgment remains a critical element in the diagnostic pathway.a There are several articles in the literature touting herniography in the evaluation of inguinal hernias. While this test is a possibility, it requires an injection of contrast material into the abdominal cavity. This may be an accurate test, but it is rarely performed as a routine procedure. If the patient truly had hip pain, the Health Insurer would have been correct in its reasoning. However, based on the provideras note, there is no indication that the patientas pain was related to her hip joint. Therefore, CT of the pelvis (72193) performed on 5/05/21 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found the records document ongoing and unremitting major depressive disorder with multiple hospitalizations for suicide attempts and ongoing suicidal ideation.  She has tried and failed antidepressants from different categories, for adequate duration and at adequate dosage.  Augmentation was attempted, which also failed.   Psychotherapy, in a variety of modalities, provided little relief as well.  She received an initial course of TMS, with dramatic improvement.  Given that she showed a dramatic improvement in symptom reduction, with rapid return of depressive symptoms on discontinuation of treatment, she required a maintenance course. Based upon the degree of treatment refractory depression, and that she has shown this level of responsiveness to treatment, further TMS treatment is appropriate.  Thus, TMS provided from 9/15/16 through 4/17/17 was and is likely to be of greater benefit 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 49-year-old male enrollee has requested reimbursement for CPT 83516 (Immunoassay, nonantibody) performed on 7/20/19. 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 this patient had type 2 diabetes and a history of pulmonary embolism. He presented for a routine examination. On 7/08/19, the patient reported no complaints. Prostate-specific antigen testing was ordered as well as CPT code 83516. There is no diagnosis of keratoconjunctivitis, sicca syndrome or inflammatory dry eye syndrome. The patient had no examination findings or other abnormal laboratory testing. The diagnosis of diabetes mellitus or pulmonary embolism does not necessitate the requested test of CPT 83516, immunoassay, non-antibody. In sum, CPT 83516 performed on 7/20/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested authorization and coverage for nursing care in the home (S9124). 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 sustained significant disability as a result of anti-NMDA-receptor encephalitis with subsequent encephalopathy. As a result of this ongoing disability, he has a number of skilled nursing needs as described above. These are not custodial needs. He requires constant monitoring for seizure necessitating rescue medication, respiratory distress necessitating application of supplemental oxygen, and gastrostomy care. Without the expertise of skilled nursing, he may experience further disability and compromise. Therefore, the requested nursing care in the home (S9124) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 48-year-old male enrollee has requested reimbursement for Prometheus Anser IFX test performed on 8/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of ankylosing spondylitis and sacroilitis plus peripheral inflammatory arthritis. The physician reviewer found the patient had been stable on Remicade for a long period of time but has experienced recent flaring. This test has been used to identify whether or not antibodies to Remicade are present in those patients currently on the medication. The results from this test assist providers in identifying appropriate therapy for the treatment of their patients. In this patients case, the provider needed to determine if antibodies to Remicade were present. The provider wanted to determine if the patients recent flares were due to a loss of response to Remicade, secondary to antibodies. If this was the case, the medication would have needed to be changed immediately. In this patients case, the test was an effective tool in assisting the patients provider with the management and treatment of this patient. In sum, the Prometheus Anser IFX test rendered on 8/24/15, was more likely to be effective than other standard methods in the evaluation of this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 63-year-old female has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pain. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. This patient has a history of prior lumbar spine fusion from L3 to the sacrum. According to the records, she has low back pain, buttock pain and radicular symptoms.  She reportedly had a positive response to a diagnostic sacroiliac injection, but the laterality of the procedure and the pain relief from the procedure are not documented.  The literature does not support the efficacy of sacroiliac joint fusion for the treatment of low back pain and buttock pain with high quality evidence.  In this case, the requested sacroiliac joint fusion is not likely to be more efficacious than other treatment alternatives. 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: Upheld

Summary Reviewer 

A 32-year-old female enrollee has requested authorization and coverage for Stelara 90 mg/mL every 28 days. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Stelara has been approved by the U.S. Food and Drug Administration (FDA) for psoriatic arthritis. As per the FDA and manufacturer recommendations for the treatment of psoriatic arthritis, the recommended dose is 45 mg initially and four weeks later, followed by 45 mg every 12 weeks. For patients with co-existent moderate-to-severe plaque psoriasis weighing more than 100 kg, the recommended dose is 90 mg initially and four weeks later, followed by 90 mg every 12 weeks. In this patients case, the requested dosage exceeds what is considered standard of care and may result in morbidity. There are alternative standard of care options for the treatment of this patients psoriasis arthritis and ulcerative colitis which may be considered before stepping outside of the standard of care. Other treatment options include adding a disease-modifying antirheumatic drug, such as methotrexate, sulfasalazine or Imuran to standard dosed Stelara, or changing to an anti-tumor necrosis factor agent, such as Humira, Remicade or Simponi. Therefore, Stelara 90 mg/mL every 28 days is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 62-year-old female enrollee has requested reimbursement for carotid duplex scan performed on 4/26/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees right carotid bruit. The physician reviewer found that Carotid artery disease is considered asymptomatic in the presence of narrowing of the internal carotid artery without a history of symptoms or physical examination findings consistent with ischemia in the ipsilateral carotid territory.  Nonspecific symptoms, such as dizziness and lightheadedness, are not indicative of carotid stenosis. Therefore, patients with these symptoms are considered asymptomatic. Guidelines from the U.S. Preventive Services Task Force do not recommend screening for carotid artery stenosis for patients that are asymptomatic. Furthermore, there is a lack of evidence that the auscultation of the neck to detect carotid bruits is accurate or provides benefit.  In this case, the documentation does not support that the patient had symptoms which were concerning for carotid artery stenosis.  She is considered asymptomatic, as she has not had symptoms that would indicate ischemia in the ipsilateral carotid artery territory of the brain. Thus, carotid duplex scan performed on 4/26/17 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 56-year-old female enrollee has requested authorization and coverage for Effient. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition status post aneurysm. The physician reviewer found that Thromboembolic complications are the main problem in stent-assisted coil embolization of unruptured intracranial aneurysms. The combination of aspirin and clopidogrel is generally used to decrease these complications, but some patients do not respond to clopidogrel and have a higher risk of stent thrombosis. Clinical trials have shown that Effient reduced the incidence of ischemic events in patients with acute coronary syndrome compared with clopidogrel. Effient reduces the consequences of thromboembolic complications of endovascular treatment with stenting and coiling of unruptured intracranial aneurysms. All told, the requested Effient is medically necessary for treatment of this patients medical 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 


A 63-year-old male enrollee has requested authorization and coverage for once a month injection of Nucala. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees asthma and eosinophilic lung disease. The physician reviewer found that the medical literature supports the requested medication in this clinical setting. In addition, this medication therapy has been given approval by the U.S. Food and Drug Administration (FDA) for the treatment of severe persistent uncontrolled asthma. The patient is greater than 12 years old and the medication has been prescribed by an allergist. The records show that this patient has asthma, which is severe. The patient has elevated blood eosinophil count, which is 150 or higher. The patient has been on maximum dose of Symbicort, which is an inhaled steroid for at least three consecutive months with no response, oral steroids (prednisone), Spiriva, and Albuterol. This patients asthma symptoms continue to be uncontrolled despite therapy and his forced expiratory volume 1 is less than 80%. The patient meets the FDA indication and criteria for the medication Nucala. As such, once a month injection of Nucala is medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.