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

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for fetal sex chromosome analysis, circulating cell-free fetal DMA in the maternal blood provided on 6/13/19. 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 was 11 weeks and 2 days pregnant when she underwent prenatal testing with Harmony Noninvasive Prenatal Testing. The testing combined both noninvasive prenatal testing (CPT codes 81507) and sex chromosome analysis for gender determination (CPT code 81599). According to the American College of Genetics and Genomics, Providers should make efforts to deter patients from selecting sex chromosome aneuploidy screening for the sole purpose of biologic sex identification in the absence of a clinical indication for this information. In this case, the patients clinical records do not suggest a specific concern for sex chromosome aneuploidies. Sex chromosome analysis via cell-free DNA methods was not clearly indicated in this case. In addition, without a specific indication, management of the pregnancy would not change by having this information. Sex chromosome analysis is not indicated via cell-free DNA for general screening at this time. Thus, fetal sex chromosome analysis (CPT 81599) performed on 6/13/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

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 distinguishing between type 1 and unusual presentations of type 2 diabetes can sometimes be difficult. The presence of antibodies to glutamic acid decarboxylase (GAD) in patients with presumed type 2 diabetes can help identify patients who may have type 1 diabetes. Autoantibody measurement is indicated when the diagnosis of type 1 or type 2 diabetes is uncertain by clinical presentation, when there is a personal or family history of autoimmune disease, or in overweight or obese children or adolescents presenting with apparent type 2 diabetes, who actually may have an early presentation of type 1 diabetes. In this case, the patient has a history of type 2 diabetes with typical presentation, and no personal or family history of autoimmune disease. Although he had an episode of ketoacidosis, this was the unusual case of a type 2 diabetic presenting with ketoacidosis due to an acute illness (i.e. pulmonary embolism). There is a lack of support for the services at issue in this clinical setting. Therefore, 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: Upheld

Summary Reviewer  
The patient is an 18-year-old female who presented to her provider on 10/22/21. The patient has 
requested authorization and coverage for sinus surgery (31267 x 2, 31259 x 2, 31276 x 2, 61782 
and 30140 x 2). The physician reviewer found that while sinus surgery can be an appropriate 
therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, the criteria 
have not been met in this patient. The American Academy of Otolaryngology Head and Neck 
Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by 
inflammation of the mucosa of the nose and paranasal sinuses with associated signs and 
symptoms of 12-week consecutive duration. CRS is characterized by two or more symptoms, one 
of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal 
drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic 
evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or 
air fluid levels in the sinuses. The AAOHNS defines recurrent acute sinusitis as four or more 
recurrent episodes of acute rhinosinusitis with complete clearing of symptoms between episodes 
over a one-year period. In this patients case, chronic rhinosinusitis was not documented in this 
patient. There was no documentation of 12 weeks of consecutive disease. Recurrent acute 
sinusitis was not documented in this patient. There was no documentation of four or more 
recurrent episodes over a one-year period. There was no documentation of chronology of 
disease, symptoms or treatment. There was no documentation that  she was treated with 
maximal medical therapy prior to the CT scan. On review of the scan, only a retention cyst in the 
maxillary sinus was present. There was minimal mucosal disease on the CT scan. Therefore, sinus 
surgery is not medically necessary in this patients case. Additionally, there was no report of nasal 
obstruction secondary to turbinate hypertrophy, refractory to medical management. Therefore, 
turbinate reduction surgery is not medically necessary. All told, the requested sinus surgery 
(31267 x 2, 31259 x 2, 31276 x 2, 61782 and 30140 x 2) is not medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for inpatient hospital stay provided from 8/5/15 through 8/6/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the medical necessity for the inpatient hospital stay provided from 8/5/15 through 8/6/15 has not been established in this clinical setting. On 8/5/15 the patient presented to the ED following an episode of altered level of consciousness. The patient did not have a significant history of cardiovascular disease. At the time of admission, the patient was described as being awake and alert, without any new focal neurologic or cardiac findings. The laboratory studies and imaging performed in the ED were unremarkable. None of the patients testing results revealed pathology that required complex therapy or that prompted urgent intervention. Finally, no complicating event occurred during the course of the hospital stay to require an escalation in the patients level of care, or to necessitate more intense monitoring. The patient was discharged from the hospital on 8/6/15 with plans to follow up at a later date. In sum, the documentation provided failed to support the medical necessity for inpatient admission on the dates in dispute. 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: Overturned

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested reimbursement for mental health program services provided from 4/20/15 through 6/25/15. 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 according to medical literature for adolescents receiving treatment in residential care for the types of behavioral health problems demonstrated by this patient, continued stay is medically necessary if the patient identifies with the severity of the drug problem and manifests insight into his personal relationship with mood-altering chemicals yet does not demonstrate behaviors indicating that he is developing problem solving skills necessary to cope with the problem and would probably relapse if moved to a lesser level of care. The material from the weekly case notes indicates that during the time period in dispute from 4/20/15 through 6/25/15, the patient was working slowly but steadily toward a better understanding and acceptance of his substance abuse and the role it played in his life.  However, the first documentation that he was actually successful in using his coping skills was the weekly case note dated 5/7/15. At that point, he would have been safe to have been transitioned to a lower level of care to continue his treatment. For these reasons, continued mental health program services were medically necessary from 4/20/15 through 5/7/15 but not thereafter. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. Specifically, dates of 4/20/15 through 5/7/15 were medically necessary. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST). The physician reviewer found that the submitted records do not support the superior efficacy of the services at issue in this clinical setting. The record and clinical examination, history and features of this case do not suggest a diagnosis of NF1. The test requested by the treating provider was performed to test the primary tumor for NF1. Genetic testing for NF1 is a simple blood test. The FoundationOne test, which tests for a large number of genes is unproven and experimental. There is a lack of prospective randomized controlled studies showing improved outcomes correlating the results obtained from similar tests with improved overall survival, progression-free survival, or quality of life. These tests, while they may discover actionable genes, have yet to be correlated with improved outcomes. The services at issue are not recommended by governing scientific bodies such as the National Comprehensive Cancer Network. In sum, FoundationOne testing performed on 4/7/15 was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to have been 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 59-year-old male enrollee has requested authorization and coverage for cryosurgical ablation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees thymoma. The physician reviewer found that thymoma is the most common primary tumor of the anterior mediastinum and often recurs after initial surgical resection.  In patients with recurrent disease and inability to perform further resections due to lack of pulmonary reserve or unresectability of the metastatic disease, cryotherapy may serve as a useful adjunct to chemotherapy and radiation therapy. A recent review article by Abtin and colleagues noted that percutaneous cryoablation shows promise as a safe and effective treatment modality for recurrent thymoma.  The relative rarity of this diagnosis limits the availability of large scale, prospective clinical trials.  However, current medical literature cites a high success rate for long-term tumor ablation. A recent review article by Zhang and colleagues noted that, In conclusion, cryotherapy is a safe and efficient method for the treatment of unresectable malignant thymoma. Thus, the requested cryosurgical ablation is medically necessary for 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 2


A 63-year-old male enrollee has requested authorization and coverage for transcatheter radiofrequency ablation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees paroxysmal atrial fibrillation.   The physician reviewer found the records document that this patient was symptomatic having sustained a cryptogenic cerebrovascular accident prior to the initiation of anti-coagulation treatment. The provider noted that the patients work as a contractor places him at considerable risk if lifelong anti-coagulation were required. In addition, he cannot tolerate the use of anti-arrhythmic therapy, which could provoke prolonged episodes of asystole prompting the need for permanent pacing. Furthermore, the patient is currently experiencing frequent symptoms associated with periods of atrial fibrillation with rapid ventricular response as well as bradycardia in the form of dyspnea and unexplained weakness. For these reasons, the patient would best be served by pulmonary venous isolation with his providers recommendation to employ radiofrequency ablation as the technique to accomplish this therapy. Accordingly, the requested transcatheter radiofrequency ablation is 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 requested service is 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 female enrollee has requested authorization and coverage for Repatha sureclick 140 mg/mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has a history of coronary heart disease. The physician reviewer found that the documentation provided supports the medical necessity for the requested medication. Based on the records, the patient has known coronary disease and severely elevated LDL, even while on statin therapy. She also has documented intolerance to multiple statin medications including atorvastatin, rosuvastatin, simvastatin and Vytorin. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Since this patient has documented intolerance to several high intensity statin medications, even at low doses, as well as some moderate intensity statins, it is unlikely that any tolerable statin would be sufficient to lower her LDL without requiring additional LDL lowering medication such as Repatha. In this clinical setting, Repatha has been shown to improve cardiac outcome. As such, the Repatha sureclick 140 mg/mL is medically necessary for the 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for mental health residential treatment provided from 6/10/16 through 9/16/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. With regards to risk of harm, the records support a score of 4. The records documented suicidal gestures/attempts and injury to others. The documentation noted a history of marked impulsivity and poor judgment. In terms of level of support of the recovery environment, the records support a score of 2. The patient had a supportive environment. With regards to functional status, the records support a score of 3. The patient had issues in school, and his learning was adversely impacted by attention deficit/hyperactivity disorder. In terms of resiliency and treatment history, the records support a score of 5. The patients response to prior treatment had been minimal. With regards to comorbidity, the records support a score of 1. The patient had no comorbidity. In terms of acceptance and engagement of the child, the records support a score of 3. The patient had a history of rejecting clinical providers. With regards to level of stress of the recovery environment, the records support a score of 3. The patients family had limited ability to respond to the patients development. In terms of acceptance and engagement, the records support a score of 2. The patients parents had a history of developing therapeutic relationships with care providers. Thus, the patient has a composite score of 23. Based on this score, residential treatment level of care was medically necessary. Thus, mental health residential treatment provided from 6/10/16 through 9/16/16 was medically necessary for the treatment of this patient. Therefore, the services at issue were 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 47-year-old male enrollee has requested authorization and coverage for endovenous vein ablation (CPT code 36478). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees varicose veins. The physician reviewer found that there is sufficient support in the medical literature and in the documentation provided for the requested services in this clinical setting. The patient has satisfied requirements with regard to symptom impact and conservative treatment use. The issue is the treatment of the perforator veins. There is good evidence to treat a symptomatic anterior accessory saphenous vein, whether by ablation or phlebectomy depending on the anatomy. In sum, endovenous laser vein ablation (CPT code 36478) is likely to be more effective for treatment of this patients medical condition than the standard therapy available.

Based upon the information set forth above, the requested services 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: Overturned

Summary Reviewer 1


A 28-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma and shortness of breath. The physician reviewer found that to date the three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up (Cox, et al). The RISA study examined the safety of thermoplasty and found short term worsening in symptoms, but evidence of improved long term control of asthma (Pavord, et al). Finally, the AIR2 trial compared thermoplasty with a sham procedure and followed the patients out for 12 months as well (Castro, et al). Overall, the data supports the short- and long-term benefits of bronchial thermoplasty for patients who fail to improve despite maximal medical therapy. This patient is on an aggressive regimen and further the notes indicate that she is not a candidate for omalizumab. The patient has undergone an extensive evaluation and is on therapy for several associated conditions which could worsen her asthma control. Since these interventions have not ideally controlled her asthma, bronchial thermoplasty is the logical and appropriate next step in management and likely to be more beneficial than any available standard therapy. Based upon the information set forth above, the requested procedure is 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 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. 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 in this case, the patients headache diagnosis is unclear and does not appear to meet specific guidelines based on the International Classification of Headache Disorders. The records report bilateral tenderness of the occipital nerves. However, there is no mention of the quality and intensity of pain (i.e., paroxysmal, sharp, shooting pain) suggestive of occipital neuralgia. In addition, there is no mention of other pain management methods recommended or used prior to the occipital nerve blocks. In sum, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were not likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 52-year-old male enrollee has requested authorization and coverage for implant stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees complex regional pain syndrome to his right foot. The physician reviewer found that there is a lack of support for the superior efficacy of the requested services in this clinical setting. This patient is being treated for chronic right lower extremity pain including a diagnosis of CRPS. He has a spinal cord stimulator. In terms of dorsal root ganglion (DRG) spinal cord stimulation, this modality is considered to be comparable to traditional spinal cord stimulator in terms of pain relief and associated benefits. The positional nature of the current coverage indicates that an assessment of the reason for inadequate coverage should be performed. Lead migration may have occurred or there may be failure of the generator or other components. Attempts at reprogramming or lead revision would be alternatives. As such, an implant stimulator for the treatment of the patients medical condition is not likely to be more effective than the available standard therapy.Therefore, for the reasons stated 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.