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

Summary Reviewer 3

A 57-year-old female requested reimbursement for magnetic resonance imaging (MRI) provided on 9/2/16.The Health Insurer has denied this request and reported that the service at issue was  considered investigational for evaluation of the enrollee who has a history of breast cysts. The physician reviewer found that in the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR) have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation. The accepted indications for diagnostic MRI of the breast is to evaluate extent of disease in patients with invasive, carcinoma or ductal carcinoma in situ (DCIS), in assessing invasion deep to the fascia, post lumpectomy with positive margins, or following patients with neoadjuvant chemotherapy. There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  As noted by Weinstein, It is thought that there is inconclusive evidence regarding MRI screening of women with a personal history of breast cancer, lobular carcinoma in situ, atypical lobular hyperplasia, atypical ductal carcinoma, dense breast tissue, and lifetime risk levels of 15% to 20%.   The patient also has some breast pain and lumpiness in her breasts.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  As noted in a recent survey by Howard, Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy. Overall, MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. All told, MRI performed on 9/2/16 was not likely to have been of greater benefit over the standard modalities of evaluating this patients medical condition. Based upon the information set forth above, the service 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 


A 60-year-old female enrollee has requested authorization and coverage for lumbar fusion surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees low back pain.The physician reviewer found that the lumbar fusion and decompression is utilized to prevent motion of the spine and to shield load bearing across deteriorated spinal joints that can cause pain or neurological disability. The International Society for the Advancement of Spine Surgery (ISASS) guidelines support the use of fusion for the treatment of degeneration disease without spondylolisthesis where conservative management has failed. The ISASS guidelines are also consistent with the standard of care. Evidence of spondylolisthesis is not required and it is a contradiction to the national guidelines referenced above. In sum, guidelines and standard practice support lumbar fusion as medically necessary for treatment of the patients degeneration of the lumbar spine. Therefore, the requested surgery 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 64-year-old female with a history of transient ischemic attacks characterized by headache, dizziness, and blurred vision. She has hypertension and is neurologically intact.  She is currently being treated with aspirin and Plavix.  On 2/27/18, she underwent left internal carotid artery angioplasty and stenting. Cerebral perfusion study showed diminished perfusion in the region of the right posterior cerebral artery. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. There is sufficient support for the requested services in this patients case. There is a demonstrated cause of the transient ischemic attacks. The records document right vertebral artery stenosis of a significant degree. The patient is at high risk for a brainstem stroke. She has not responded to pharmacological therapy. Therefore, the requested vertebral artery angioplasty is likely to be of greater benefit than other treatment options. 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: Upheld

Summary Reviewer 1


A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature suggests that continued research is still necessary to develop clear guidelines for the usage of pharmacogenetics testing. Therefore, pharmacogenetics testing is not considered the standard treatment. However, in this case, the patient has already been treated with eight different antidepressants, with at least three different pharmacodynamic strategies, and has not had a good response. Given that she has failed the standard treatments that are available, the pharmacogenetics testing was medically reasonable in this clinical setting. The genetic testing has the potential to guide the providers decisions to medications that will be better tolerated and more effective. Therefore, the gene testing performed on 8/11/16 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 testing 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 overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that contrast-enhanced breast MRI is more sensitive for the detection of breast cancer in the high risk population than both mammography and ultrasound. Screening breast MRI is recommended in women with BRCA gene mutations, their untested first-degree relatives, and women with a lifetime risk of greater than 20%. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. A common screening protocol is alternating MRI with mammography/ultrasound every six months. This patient has a known BRCA1 gene mutation and is therefore considered one of the highest risk populations for breast cancer. She is alternating mammography/ultrasound with MRI every six months. Due to pregnancy and subsequent breastfeeding, she was unable to obtain her annual screening MRI, which would have been due February 2017. Therefore, MRI was appropriately performed in January 2018 after the cessation of breastfeeding, according to her screening schedule. Thus, bilateral breast MRI performed on 1/28/18 was likely to have been of more efficacious than other modalities for evaluating this patient. 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: Upheld

Summary Reviewer 2

A 32-year-old male enrollee has requested reimbursement for gene testing performed on 3/12/19. 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 has 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 study. 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. This patient had an early stage melanoma with good prognostic features on pathology. In sum, gene testing performed on 3/12/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 41-year-old transgender female who has been diagnosed with gender dysphoria. In a letter dated 11/05/19, the provider noted that facial feminization surgery was a medically necessary treatment of her gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, improved mental health-related quality of life. The World Professional Association for Transgender Health (WPATH) position statement noted non-genital surgical proceduresnotably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitalsThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. Therefore, surgery (67900, repair of brow ptosis, 21121, genioplasty, 31599, unlisted procedure larynx, 30410, rhinoplasty, 21138, reduction forehead, contouring and application of prosthetic material or bone graft, 21295, reduction of masseter muscle and bone, 21172, reconstruction superior-lateral orbital rime and lower forehead, and 20926, tissue grafts) provided on 12/09/19 with associated inpatient admission were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 51-year-old female enrollee has requested authorization and coverage for placement of graft to hold open nasal valves, repair of nasal fracture and transfer tissue on a pedicle. 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 has a long history of nasal obstruction. She has daytime somnolence and has an RERA index of 40.4 events per hour. Her examination shows septal deviation, turbinate hypertrophy, and internal and external valve collapse. After decongestion, her nasal breathing still did not improve, indicating significant nasal valve obstruction. Her provider has recommended cartilage graft to repair nasal valves and temporalis fascia graft. Internal and external valve repair of the nose are standard procedures for the improvement of nasal airway. Assessment and treatment of these in conjunction with the nasal septum and turbinates is important in improving nasal function. Per the submitted documentation, the denied procedure codes are 30465, 21335, 20912, 20902, 20910, 21235 and 15570. In this patients case, the following services are medically necessary: 30520 (septoplasty), 30140-50 (inferior turbinate submucous resection), 30465 (vestibular stenosis repair), 21335 (open treatment of nasal fracture), and 20912 (cartilage graft septum). There is no documentation to support the need for a tubular flap, bone graft, temporalis fascia graft, or ear cartilage. Therefore, a portion of the requested services is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
A  52-year-old  female  enrollee  has  requested  authorization  and  coverage  for  the  Intracept 
procedure. The Health Insurer has denied this request and reported that the requested medication 
is investigational for the treatment of the enrollees low back pain. The Health Insurer indicated 
that the requested service is investigational for the treatment of the enrollees medical condition. 
Therefore, the Health Insurer has denied coverage for the requested service. The physician reviewer 
found that the Intracept procedure is a promising, minimally invasive treatment option for patients 
with isolated vertebrogenic pain. Good therapeutic results can only be achieved through proper 
patient selection. Current medical literature includes data from randomized controlled studies 
including patients with isolated lumbar back pain as their chief complaint for treatment. The 
studies specified exclusion criteria in order to avoid overlapping pain sources including the 
presence of other concomitant symptoms related to spine pathology that could easily obscure the 
clinical presentation and make it difficult to isolate vertebrogenic pain as the main problem to be 
treated such as previous spinal surgery, radicular pain symptoms, neurogenic claudication, or 
radiographic evidence of spinal pathology or other possible pain sources. In this case, notes dated 
8/23/22 reported that the patient has had chronic back pain for many years that has not responded 
well to conservative measures such as medications, epidural injections, or physical therapy. While  MRI images were not provided for review, the MRI report dated 7/1/22 reported moderate facet 
arthropathy and canal narrowing at L3-L4 and L4-L5, which can present with back pain that is 
similar to the patients clinical picture and is difficult to differentiate from isolated vertebrogenic 
pain. More importantly, the MRI report does not mention Modic changes at L2-L3 level, as stated 
by the provider. Given that the MRI report does not mention Modic changes at L2-L3, along with 
the unclear course of the patients recent physical therapy program, it cannot be concluded at this 
point that the requested service would be more beneficial for the patient than other standard 
conservative therapies for management of low back pain. Therefore, the Intracept procedure is not 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 60-year-old female with a diagnosis of psoriatic arthritis. The patient has requested authorization and coverage for Cosentyx. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that although the patient has tried and failed multiple prior therapies for her psoriatic arthritis, she has not tried and failed the additional plan preferred therapies that are not truly medically contraindicated, including Humira, Cimzia Simponi or Stelara. A family history of skin cancer does not constitute a contraindication to any of the preferred therapies. Additionally, Stelara is a drug with a different mechanism of action than the anti-tumor necrosis factor agents that the provider is concerned about. Dobbin-Sears and colleagues noted that Ustekinumab is used in the treatment of psoriatic arthritis following the failure of nonsteroidal anti-inflammatory drugs and conventional disease-modifying antirheumatic drugs (DMARDs), and as an alternative to, or after failure of, an anti-tumor necrosis factor agent. Stelara remains a preferred alternative which is medically appropriate in this setting. Therefore, Cosentyx is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 67-year-old male enrollee has requested authorization and coverage for a split night polysomnogram. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the records indicate that this patient has a prior history of OSA and remains symptomatic. Testing would have been indicated to re-establish a diagnosis of OSA. However, provision of services in the attended setting would have exceeded the patients clinical needs. The current literature indicates that there has been a shift from the provision of services in the attended setting to the ambulatory setting (Jordan, et al). Unattended and attended testing have been shown to yield equivalent outcomes to laboratory testing in at least two randomized trials (Rosen, et al; Chai-Coetzer, et al). The performance of testing and treatment in the home setting has also been shown to produce equivalent outcomes to testing in the attended environment. There were no extenuating circumstances present in this patients case that would have warranted an attended sleep study. The patients sleep related presentation was most consistent with OSA. While he reported nocturnal limb movements, it would be more appropriate to evaluate and treat the OSA to see if the limb movements are due to respiratory related arousals. Moreover, he has no other medical conditions that are a contraindication to provision of services in the home setting. Accordingly, the requested split night polysomnogram is not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a six-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg click easy cartridge.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition The physician reviewer found growth hormone therapy is indicated for the treatment of growth failure in children born small for gestational age who fail to manifest catch-up growth by two to four years of age.  Most infants who are small for gestational age have sufficient postnatal catch-up growth to normalize their stature by two years of age.  Growth hormone therapy is a recognized therapy for children who are born small for gestational age, but who fail to have catch-up growth.  Thus, Saizen 8.8 mg click easy cartridge is likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested medication 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: Upheld

Summary Reviewer 

A 44-year-old female enrollee has requested authorization and coverage for Nucala 100 mg SQ every 4 weeks. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request for Nucala has not been established as medically necessary for treatment of the patients medical condition. Nucala is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with severe asthma despite maintenance treatment with an inhaled steroid and a long term adrenergic agonist. In this case, the patient has asthma, however the documentation submitted for review does not support the patient has severe asthma. In addition, the patient has vocal cord dysfunction. Nucala is not FDA approved for the treatment of vocal cord dysfunction. In sum, there is insufficient documentation to substantiate that this patient has severe asthma. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. Given the above reasons, the requested medication is 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 


The parent of a six-year-old male enrollee has requested authorization and coverage for Nutropin AQ. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has normal stature, normal growth velocity, normal bone age, and normal IGF-1.  Provocative growth hormone testing showed a peak growth hormone response of 14.1 ng/mL, with a normal result being a peak growth hormone level greater than 10 ng/mL on at least one sample obtained after two provocative growth hormone tests.  Thus, the patient does not meet auxological or biochemical criteria for growth hormone deficiency.  Growth hormone therapy is not an indicated treatment for fatigue/somnolence in the absence of auxological or biochemical evidence of growth hormone deficiency.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

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 there is sufficient support for the services at issue in this clinical setting. This patient had continued anterior pain and pain with hip flexion after total hip arthroplasty. He had exhausted conservative care, and his provider recommended iliopsoas tendon lengthening. The procedure performed is a well-accepted surgical treatment for iliopsoas tendinitis after total hip arthroplasty in select patients. This patient had trialed medication and activity modification prior to surgery.  The surgery performed was likely to have been more beneficial than any available standard treatment. The only available standard treatment is open lengthening, which is a highly invasive intrapelvic procedure. Therefore, CPT code 29999 (left hip iliopsoas lengthening and left hip subspinal decompression) performed on 8/27/18 was likely to have been superior over other treatment options.