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

Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for Fragile X mental retardation 1 laboratory testing (81243) performed on 8/09/19. 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 Prenatal screening for fragile X syndrome is not currently a part of universal screening in terms of genetic testing for routine prenatal care. The testing is performed to identify individuals at risk for conceiving a child with clinical manifestations of the disorder. Per the American College of Obstetricians and Gynecologists (ACOG), screening for fragile X syndrome is offered in women after a careful assessment of the family history is performed to identify individuals with sufficient likelihood of premutation or full mutation carrier status to warrant such screening.  The following is used as criteria for such screening: individuals seeking reproductive counseling who have a family history of fragile X syndrome (confirmed premutation or full mutation of FMR1 gene) or intellectual disability of undetermined etiology; individuals of either sex with intellectual disability or developmental delay of undetermined etiology, or autism; young women with elevated levels of follicle-stimulating hormone, especially with a family history of premature ovarian insufficiency (menopause before age 40), fragile X syndrome, or a relative of either sex with intellectual disability of undetermined etiology; and individuals with late-onset intention tremor or ataxia (usually after age 50), especially with a history of infertility, family history of movement disorders, fragile X, or intellectual disability of undetermined etiology. Universal screening is not offered, in part, due to the difficulty in predicting phenotype in offspring of low-risk women (women with a negative personal and family history) with a premutation. Given the clinical documentation, there is no clear support that the patient is at high risk to warrant screening.  Therefore, fragile X mental retardation 1 laboratory testing provided on 8/09/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 54-year-old male who has a history of bilateral nasal congestion. In a letter dated 6/26/20, the provider noted that the patientas symptoms include no nasal discharge, difficulty breathing, no postnasal drip, no sinus pain, no headaches, no sore throat, and no ear fullness.The patient has requested authorization and coverage for repair nasal vestibular stenosis (CPT 30465). 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 the submitted documentation supports the medical necessity of the requested services. This patient has bilateral nasal obstruction. He has enlarged turbinates, deviated septum and valve collapse. A Cottle maneuver showed improvement of nasal breathing, indicating nasal vestibular stenosis. The provider is planning on septoplasty, bilateral turbinate reduction, and repair of bilateral vestibular stenosis. Vestibular stenosis is diagnosed by observing valve collapse and a positive Cottle maneuver. Not repairing the vestibular stenosis will cause the patient to continue to have difficulty with nasal obstruction. Expanding the nasal valve is essential in improving nasal obstruction in patients with valve collapse. Therefore, the requested repair nasal vestibular stenosis (CPT 30465) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
The parent of a 16-year-old female enrollee has requested reimbursement for intra-operative 
electromyography (EMG) monitoring and neuromuscular junction testing during spinal surgery 
including anterior cervical procedures on 2/14/22. The Health Insurer has denied this request 
indicating that the services at issue were investigational for the treatment of the enrollee. The 
physician  reviewer  found  that  the  patient  had  idiopathic  scoliosis  and  required  surgery. 
Intraoperative neuromonitoring including electroencephalogram (EEG) and EMG are routinely 
used for pediatric spinal surgery to reduce the risk of neurological injury. Sindou and colleagues 
suggest that external anal sphincter EMG recording is useful to avoid sacral root injury during 
spinal  surgery.  Buckwalter  and  colleagues  report  that  out  of  579  surgical  cases,  3.6% 
neuromonitoring changes occurred in 3.6% of the cases, for which no permanent harm was done 
to the patient if corrective actions were performed. Krishnakumar and Srivatsa report that the 
combined  multimodal  intraoperative  monitoring  helps  in  increasing  the  safety  in  scoliosis 
corrective  surgeries  with  a  high  sensitivity  and  specificity.  Therefore,  intra-operative  EMG 
monitoring and neuromuscular junction testing during spinal surgery including anterior cervical 
procedures on 2/14/22 was likely to have been more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 31-year-old male enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) level of care services provided from 3/1/16 and 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 medical condition status post right hip revision surgery.  The physician reviewer found the medical records support the medical necessity of the continued treatment at a SNF as of 3/1/16 as recommended by this patients medical providers for the management of complex issues of T11 level paraplegia and a complex intratrochanteric fracture of the right hip requiring revision hemiarthroplasty and complex ORIF techniques. Multiple comorbidities are likely to be improved with decisions as to transfer to a lower level of care once the patient has achieved stated goals. The totality of medical care reasonably includes care at a SNF until such time as risks of decubitus, bladder infection, loss of fracture stability, and avoidance of hip dislocation have all been addressed to the satisfaction of the patients providers. All told, the SNF services at issue from 3/1/16 and forward are medically necessary for treatment of this patients medical condition. For these reasons, 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
A 44-year-old female enrollee 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 sacroiliac joint pain. The physician reviewer found that Sacroiliac fusion maybe recommended as a last line of therapy (including either open or minimally invasive procedures) as treatment for sacroiliac joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or sacroiliac pain due to severe traumatic injury. The procedure may be required for multisegmental spinal constructs (i.e., scoliosis or kyphosis surgery). However, it is not recommended for mechanical low back pain, non-specific low back pain, sacroiliac joint disruption (in the absence of major pelvic fracture), degenerative sacroiliitis, sacroiliac joint osteoarthritis, or sacroiliac joint-mediated pain (other than pain due to etiologies noted above). In this case, the patient has been diagnosed with left sacroiliac joint dysfunction. She has physical examination findings which localize her symptoms to the left sacroiliac joint. However, there are no objective imaging or laboratory findings to indicate the presence of sacroiliac joint infection, tumor, sacroiliitis due to spondyloarthropathy, or post traumatic arthritis. Although North American Spine Society (NASS) does note some evidence supporting sacroiliac fusion for sacroiliac joint mediated pain, the quality of evidence is low. Thus, the requested sacroiliac joint fusion is not likely to be more effective than other available treatment options. 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 71-year-old male enrollee has requested reimbursement for CPT 29999 performed on 8/27/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that per the literature, impingement between the acetabular component and the iliopsoas tendon can cause anterior groin pain after total hip replacement. Treatment of the impingement can be nonoperative, arthroscopic, or open, with revision of the acetabular component. In the study by Filanti and colleagues, 35 patients with groin pain after total hip arthroplasty underwent preoperative evaluation, including injection of local anesthetic into the iliopsoas tendon sheath. An extensive arthroscopic debridement was performed. When there were signs of iliopsoas impingement, a transcapsular tenotomy was performed according to the Wettstein technique. The authors concluded that hip arthroscopy in treatment of anterior iliopsoas impingement is useful, more so than the open technique. Guicherd and colleagues noted that the procedure relieved pain in 92 percent of patients. Thus, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been more efficacious than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 58-year-old male with a diagnosis of ankylosing spondylitis in multiple spine areas.  The patientas provider has recommended Xeljanz XR 11 mg. The Health Insurer has denied this request and reported that the requested medication 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 submitted documentation supports the medical necessity of the requested medication. This patient has already tried the step therapy with nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, methotrexate and TNF inhibitors. In addition to ankylosing spondylitis, this patient has Crohnas disease, which makes his options limited. There is support for Janus kinase (JAK) inhibitors after failing TNF inhibitors and IL-17 inhibitors. In this patientas case, none of the IL-17 inhibitors will be appropriate since they potentially cause flare-ups and worsen his Crohnas disease. Recent medical evidence indicates that tofacitinib (Xeljanz) can be used in patients with ankylosing spondylitis as an initial therapy or after failing other therapies, especially TNF inhibitors. In addition, tofacitinib is safe for use in patients with Crohnas disease. Therefore, Xeljanz XR 11 mg is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for repair of cartilage in the left ankle joint performed on 11/14/18. 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 Osteochondral lesions of the talus occur in up to 70% of acute ankle sprains and fractures. These lesions have become increasingly recognized with the advancements in magnetic resonance imaging (MRI) scans. A fair number of these lesions can remain symptomatic and necessitate surgery. In this case, the lesion had remained symptomatic for over two years before the second surgery. Thus, additional surgery was needed. The type of surgery has included either reparative procedures, such as bone marrow stimulation, or replacement procedures, such as autologous osteochondral transplantation. Reparative procedures are generally indicated for smaller lesions, such as this one. The reparative techniques include debridement and bone marrow stimulation techniques, such as microdrilling and microfracture. Regenerative techniques include autologous osteochondral transplants utilized for larger lesions. A review of the current literature indicates drilling, microfracture and insertion of micronized cartilage and bone marrow aspirate concentrate appears to be a safe and effective treatment option for osteochondral lesions of the talus. The addition of bone marrow aspirate concentrate and micronized cartilage does not result in an increase in ankle or donor site morbidity. It is a well-tolerated therapy that significantly promotes healing and decreases revision rates for treatment of the osteochondral lesions when compared to debridement and microfracture alone. Therefore, repair of cartilage in the left ankle joint performed on 11/14/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 23-year-old female enrollee has requested reimbursement for genotype testing performed on 11/10/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health conditions. The physician reviewer found that in this patients case, the records do no document adequate trials of medications from different classes for adequate time periods with appropriate strategies, including augmentation, if appropriate.  The patient had a clinical picture complicated by substance use. In general, genetic testing results show if a patient is a normal responder of certain classes of medications, may be more or less likely to respond to certain medications, is at low risk of certain adverse events, at higher risk of others, or may have decreased activity of a certain enzymatic line. The fact that one of these results may show up on genetic testing does not necessarily indicate that one medication will, definitively, be more or less effective than another. There are other factors that influence medication efficacy, such as drug-drug interactions, variance in hepatic metabolism of each individual, and individual variances, such as substance abuse.  Studies have shown that clinically useful predictors in genetic testing are scarce for antidepressant therapy, with results being inconsistent and only marginal clinical association between enzyme system variants and drug metabolism, efficacy, and tolerability in the treatment of depression. There is a lack of large randomized trials supporting its use. The existing studies have also indicated that there was no significant correlation between either genotypes or medication serum concentration and response treatment. The current evidence does not support the use of genotyping when choosing an antidepressant, and even less is understood about its use in the treatment of anxiety disorders. Genetic testing lacks evidence based research to show its effective use in guiding the clinician towards choosing a medication regimen. In sum, genotype testing performed on 11/10/17 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 

A 51-year-old female enrollee has requested authorization and coverage for mastopexy and abdominoplasty. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who was diagnosed with breast ptosis and excess abdominal skin.The physician reviewer found that from the American Society of Plastic Surgeons (ASPS), there can be situations when skin redundancy can cause a functional deficit. Thus, mastopexy and abdominoplasty could be considered functional treatments instead of cosmetic treatments.  Shermak and colleagues also note the following, Massive weight loss leads to functional and aesthetic deformity that can be corrected with body contouring surgery. Body contouring procedures can generally be considered cosmetic intervention, except when used to treat well-defined functional deficits that have failed typical dermatologic treatment, as in this case.  This patient has chronic rashes underneath her abdominal skin folds and breasts that have failed typical dermatologic treatment.  This is supported by the patient, multiple providers, medical documentation and photographs.  The medical literature supports surgical intervention in this clinical setting where documentation indicates a lack of response to typical dermatologic treatment or to conservative management. This is well-documented for this patient.  Based on the medical records provided, there is a clear functional deficit related to the massive weight loss in the areas of concern. Moreover, the patient has also tried and failed specific dermatologic treatments. The documentation provided evidence of recurrent rashes with detailed specific dermatologic medications. In this patients case, there is well documented functional deficits along with documentation of failed therapies. As such, the requested services of mastopexy and abdominoplasty are medically necessary. Therefore, for the reasons stated above, the requested services are medically necessary for the treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for Afirma Thyroid FNA Analysis performed on 12/4/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the Afirma Thyroid FNA Analysis performed on 12/4/14 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the initial biopsy report was indeterminate. The Afirma testing revealed a benign result. This was a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on FNA samples performed on thyroid nodules. In sum, the testing at issue was 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 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 33-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) test and Factor V Leiden performed on 5/17/18. 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 deep vein thrombosis and pulmonary embolism. The physician reviewer found that women who screen positive for the Factor V Leiden deficiency are at greater risk for an adverse thrombotic event especially when faced with certain clinical situations, such as surgery, immobilization, hormone replacement, birth control pills and pregnancy. The medical management of pregnancy is very different if a patient is found to be high-risk secondary to being positive for a thrombophilia study. This patient has a personal history of deep vein thrombosis/pulmonary embolism while on birth control pills, and is a high-risk patient. Thus, Factor V Leiden testing was appropriate. However, there is a lack of support for MTHFR testing. Although some studies suggest patients are at increased risk during pregnancy, other studies have not. The risk seems to be mediated through hyperhomocysteine levels. Given the effects of folic acid decreasing these levels, it is only recommended to supplement patients with B6, B12, and folic acid. This has been done with this patient. In sum, Factor V Leiden performed on 5/17/18 was likely to have been of greater benefit than other methods of evaluating this patient. However, the superior effectiveness of MTHFR has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 68-year-old female insured has requested reimbursement for a Guardant360 CDx test provided 
on 1/19/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insured's metastatic non-small cell lung cancer. 
The physician reviewer found that the integration of next-generation sequencing (NGS) testing 
into the routine management of stage IV non-small cell lung cancer demonstrates a marked 
increase  in  the  detection  of  therapeutically  targetable  mutations  and  improved  delivery  of 
molecularly guided therapy. The National Comprehensive Cancer Network (NCCN) guidelines 
recommend liquid or plasma NGS if the patient has insufficient tissue from the tumor, or if 
expedited results are necessary. A repeat biopsy can delay care and lead to unnecessary procedures. 
In this case, the provider noted that the patient had insufficient tissue for full NGS testing. 
Therefore, the Guardant360 CDx test provided on 1/19/22 was likely to be more beneficial for the 
evaluation of the patients condition than any available standard therapy.