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

Summary Reviewer 

A 19-year-old male enrollee has requested reimbursement for 84999 performed on 10/17/18. 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 this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, CPT 84999 performed on 10/17/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested reimbursement for inpatient mental health services provided from 1/26/16 through 3/24/16.  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 the submitted documentation fails to demonstrate the medical necessity of the services at issue.  He was not a danger to himself or others.  He was not delusional or paranoid, and had no hallucinations.  The patient remained depressed, but he showed overall slow and incremental improvements in hygiene, appetite and fluid intake, participation in on and off unit groups, and communication/interaction with others.  He was cooperative and medication compliant, and he tolerated medication changes well.  Although the patient received a course of electroconvulsive therapy while hospitalized, electroconvulsive therapy is most commonly administered on an outpatient basis and there is no indication that this was needed on an inpatient basis.  All told, inpatient mental health services provided from 1/26/16 through 3/24/16 were not medically indicated for the 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: Overturned

Summary Reviewer 


The parent of a 12-year-old female enrollee has requested reimbursement for inpatient hospitalization provided from 11/14/16 through 11/17/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees complex regional pain syndrome of her right lower extremity.  The physician reviewer found that based on the presented clinical records submitted for review, the inpatient hospitalization provided from 11/14/16 through 11/17/16 was medically necessary for treatment of the patients medical condition. Complex regional pain syndrome type 1 is a pain syndrome of the extremities characterized by pain, edema, limited range of motion, skin changes, and vasomotor instability. There is typically some inciting event, after which the symptoms occur. Prompt diagnosis and a multidisciplinary approach to treatment have been shown to facilitate recovery (Harris, et al; Wasner, et al). In this case, the patient presented with an acute on chronic exacerbation of her complex regional pain syndrome, refractory to her usual medications, addition of medications, and outpatient pudendal nerve block. Following failure of outpatient management and reports of extreme pain rated at 11/10, she was admitted for ketamine infusion and CT-guided pudendal nerve block. Ketamine is used to treat chronic pain syndromes, particularly those with a neuropathic component. Because neuropathic pain involves N-methyl-D-aspartate receptor upregulation, especially in cases of central sensitization, and ketamine is thought to inhibit this receptor, it has been used in appropriately chosen cases to provide relief. Given that the patient failed outpatient management, acute inpatient management provided at a higher level of care was clinically indicated for this patient. As such, the services at issue have been established as medically necessary for treatment of the patients medical condition. Therefore, the services at issue were 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 51-year-old male enrollee has requested authorization and coverage for Octagam intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees bilateral upper extremity weakness and atrophy.  The physician reviewer found the records provided for review demonstrate that this patient developed progressive motor neuropathy that could be related to a variant of lower motor neuron syndrome. However, a variant of chronic inflammatory demyelinating polyneuropathy (CIDP), multifocal motor neuropathy or inflammatory neuropathy cannot be excluded. Considering the fact that the disease is active and progressive, a short trial of IVIG as recommended by the provider is appropriate. If the patient has an inflammatory neuropathy, he may respond to IVIG. In addition, the patients condition is active and he is losing axons. Delaying IVIG treatment in inflammatory neuropathy may limit the patients response to immunotherapy. An IVIG trial may help support or exclude the diagnosis of CIDP variant. Given this support, the requested Octagam IVIG is supported as 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: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 19-year-old female who developed symptoms of headache, lock jaw, bodily stiffness, dizziness and numbness in her legs and feet in late 2016. She was treated empirically for Lyme disease and underwent extensive testing for Lyme disease and other tick-borne diseases. The records report that the testing was unremarkable. The patient has requested reimbursement for infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and methylenetetrahydrofolate reductase (MTHFR) inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. Overall, there is a lack of peer-reviewed medical literature to support the clinical utility of the polymerase chain reaction (PCR) and MTHFR testing as performed in this patients case. The MTHFR mutation assessment has not been shown to be of value in this clinical situation given this patients symptoms, or for use in diagnosing any tick-borne disease (Long and Goldblatt). Similarly, there is a lack of data supporting the use of Lyme PCR in making a diagnosis of this patients symptoms (Waddell, et al). All told, the infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and MTHFR inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17 were 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: Experimental
Decision: Overturned

Summary Reviewer 1


A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient was at a significant risk from sudden cardiac death. He benefited from risk reduction with the wearable cardioverter defibrillator provided on 11/5/14. An increase in the risk of sudden cardiac death, and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with left ventricular dysfunction related to underlying ischemic heart disease. This patient was at risk for sudden cardiac death while awaiting improvement in left ventricular systolic function prior to consideration of a permanent ICD. Given the above, the wearable cardioverter defibrillator provided on 11/5/14 was 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: Experimental
Decision: Upheld

Summary Reviewer 3


A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found the Decision Dx melanoma gene assay performed on 10/15/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient was diagnosed with melanoma, Breslow depth 0.81 mm located on the mid lower back. Decision Dx gene testing assays gene expression in the tumor to determine the risk of metastatic disease in the following five years. The use of this testing is not considered to be standard of care. The use of Decision Dx Melanoma testing is not recommended outside of clinical trials according to the National Comprehensive Cancer Network (NCCN) guidelines for the diagnosis and treatment of melanoma. Given that this testing is not the standard of care, the testing at issue 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: Overturned

Summary Reviewer 

The patient is a 55-year-old female who has requested authorization and coverage for pembrolizumab.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the patients medical condition. This denial is the subject of this appeal and determination. The physician reviewer found that the phase III study by Schmid and colleagues demonstrated that the addition of pembrolizumab  to neoadjuvant chemotherapy consisting of weekly paclitaxel and carboplatin followed by doxorubicin or epirubicin and cyclophosphamide raised the overall pathologic complete response rate from 51 to 65 percent. While patients with programmed cell death ligand 1-expressing (PD-L1-positive) cancers had higher pathologic complete response rates whether they received pembrolizumab or not, the addition of pembrolizumab increased pathologic complete response rates in both PD-L1-positive and PD-L1-negative cancers. Use of this medication is supported by this phase III trial as well as off-label use by major drug compendia. There is sufficient support for the requested medication in this clinical setting. Therefore, pembrolizumab is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 79-year-old female who presented to her provider on 7/11/22. The records noted a 
diagnosis of BRAF V600E mutated papillary thyroid cancer with lung metastasis. The patient has 
requested authorization and coverage for the medications Braftovi SGM and Mektovi SGM. The 
Health Insurer has  denied  this request  and reported  that the  requested medications are 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 does not support 
the medical necessity of the requested medications. Iodine refractory metastatic papillary thyroid 
cancer is an incurable disease, but systemic therapy can help prolong survival. Anti-angiogenic 
kinase inhibitors are approved for thyroid cancer and recommended by multiple societies including 
the National Comprehensive Cancer Network (NCCN), European Society for Medical Oncology 
(ESMO), and American Thyroid association (ATA) for systemic therapy. In this case, the records 
do not appear to note that the patient was  previously treated with anti-angiogenic kinase inhibitors, 
having instead been treated with BRAF inhibitors. BRAF V600E mutations may be seen in 
papillary thyroid cancer, and current medical literature notes activity of BRAF inhibitors in thyroid 
cancer. The U.S. Food and Drug Administration (FDA)  approves the use  of  dabrafenib in 
combination with trametinib for unresectable or metastatic solid tumors with the BRAF V600E 
mutation. Another combination that may be used for the treatment of patients with BRAF V600E 
is binimetinib and encorafenib, although this combination is not FDA approved for the treatment 
of papillary thyroid cancer. In this case, as the patient is not tolerating the approved BRAF directed 
therapy but has other options for systemic therapy, specifically anti-angiogenic kinase inhibitors, 
the requested medications are not medically indicated. Therefore, the medications Braftovi SGM 
and Mektovi SGM are not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 27-year-old female enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999) provided on 3/28/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma.   The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma gene assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay provided on 3/28/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based on the foregoing discussion, the testing at issue was 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 

The patient is a 50-year-old female who presented to her provider on 8/14/19. She reported back pain, shoulder pain and neck pain with bra strap grooving. The physician reviewer found that the American Society of Plastic Surgeons (ASPS) has indicated the decision to perform reduction mammoplasty should be based on patient symptoms and a surgeons assessment of the likelihood of benefit as opposed to the amount (weight) of breast tissue to be removed. It has been indicated by others, however, that the ASPS position is largely based on observational studies, which are un-blinded, lack randomized control groups and have potential for selection bias, and expert opinion. The more common and accepted guidelines use a measurement of body surface area and weight removed to determine medical necessity. The gold standard for this determination is the study by Schnur and colleagues. This article does not establish a defined lower weight for breast resection. Rather, it establishes a range. In this patients case, the resection would qualify the procedure as medically necessary according to weight. The photographs documented significant breast hypertrophy, consistent with the qualified weight resection. All told, breast reduction surgery performed on 12/11/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for substance use residential treatment center services provided from 2/26/17 through 3/5/17 and intensive outpatient program (IOP) services provided from 3/6/17 through 3/29/17. 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 services at issue were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was not in withdrawals. He was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, or symptoms that would warrant the levels of care in dispute. There was a lack of evidence demonstrating a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was cooperative. He had sober support in his mother. He was motivated, however throughout both the residential and IOP dates he had frequent group dates showing that he showed up late, was distracted, or had little to no participation. The issues he was working on in both residential and IOP that included developing coping skills, accountability and family dynamics did not require the frequency of contact with providers in either of the settings in dispute. He did not require 24-hour monitoring in the residential setting. Treatment and recovery could have been provided at IOP level of care. Residential treatment level of care provided from 2/26/17 through 3/5/17 was not medically necessary. Moreover, the patient did not require IOP level of care. As of 3/6/17, he could have been treated at outpatient level of care with adjunctive 12 step attendance, and counseling if he so chose. Of note, the documentation provided for review did not show any changes in treatment plans, psychiatric admitting history, or any physician progress notes. As such, the services at issue were not medically necessary for treatment of the patients medical condition. 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 22-year-old male enrollee has requested reimbursement for inpatient detoxification services provided from 2/23/18 through 2/28/18. 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 in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation with active intent or plan. The records noted that the patient had suicidal ideation which had resolved. With regards to functional status, the records support a score of 3 due to overall fair functional level in treatment but a history of functional problems when in the community and a history of using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of mood symptoms and attention/deficit hyperactivity disorder. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment. With regards to treatment and recovery history, the records support a score of 3 due to current motivation for treatment but unclear response to treatment in the past. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 16. This score correlates with low intensity community-based services. Therefore, inpatient detoxification services provided from 2/23/18 through 2/28/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 64-year-old female who was diagnosed with rectal cancer in 2016. The biopsy indicated that it was an invasive squamous cell carcinoma. On 12/13/16, it noted that the patient had a lower anterior resection with lymph node sampling followed by concurrent radiation and chemotherapy with cisplatin and capecitabine from March 2016 through April 2016. Imaging was concerning for progressive disease. According to the records, the tumor may have been a direct extension from a neighboring site. With regressive disease, a tumor sample was sent for mutational profiling and for immunohistochemistry analysis. The patient has requested reimbursement for the CarisMI profile testing services performed on 3/10/17. The Health Insurer denied this request as investigational for the evaluation of this patients medical condition. Several large comprehensive cancer centers have instituted targeted screening of solid tumors for mutations in oncogenes that have U.S. Food and Drug Administration approved targets. This patient was noted to have progressive disease on standard therapies and so her provider decided to sequence for mutation or screen for overexpression in EGFR, BRAF, FLT3, JAK2, KRAS, NPMT, APC, and ABL1. In a study by Von Hoff and colleagues, the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors.  As such, these studies offer some rationale in support of mutational testing for patients in this clinical setting. The Physicians Data Query of the National Cancer Institute (NCI) lists targeted therapy as a treatment option for stage IV or recurrent colon cancer. The NCI provides a list of examples, many of which require special analysis of the tumor specimens. Accordingly, CarisMI profile testing services performed on 3/10/17 was likely to have been more effective than the standard forms of evaluating this patients medical condition. Therefore, for the reasons stated 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.