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

Summary Reviewer 

A 22-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. Based on the patients PHQ-9 depression score, it appears that he has serious depression. Current literature does not indicate that transcranial magnetic stimulation needs to follow numerous medication failures. This patient does not appear to have any comorbid substance abuse or personality disorders. The evidence base for transcranial magnetic stimulation has grown over the past several years, and this treatment has thereby gained U.S. Food and Drug Administration (FDA) approval for the treatment of depression. The evidence available on the use of repetitive transcranial magnetic stimulation for adults indicates that this treatment is approximately twice as effective as a sham procedure. There is supporting evidence in the literature that numerous medication trials do not often yield higher levels of success. This patient has reportedly failed several separate medication trials in the past. Based upon the patients level of depression and lack of response to antidepressant treatment and psychotherapy, the requested services are medically indicated. Therefore, transcranial magnetic stimulation is 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 physical therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees spiral fractures of left fourth and fifth metacarpals. The physician reviewer found that in the medical literature, Hagen and colleagues noted that, there is empirical evidence that exercise therapy (ET) has beneficial clinical effects for most musculoskeletal conditions (MSCs). This patient has undergone 60 sessions of physical therapy and is continuing her home exercise program. The provider reports that the patient has had forward progression in therapy, although it has been slow. While the patient is also performing a home exercise program, she has remaining deficits due to a muscular skeletal condition, which are affecting her activities of daily living. Moreover, the patient requires the services of a trained physical therapist at this time. Given these findings, the requested physical therapy is medically necessary. Based on the foregoing discussion, the requested services are 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 patient is a 49-year-old female with small intestinal bacterial overgrowth. Per the provider note dated 4/27/17, she has a history of gastroesophageal reflux disease (GERD), iron-deficiency anemia, hypertension, and irritable bowel syndrome. A hydrogen and methane breath test on 3/24/17 showed baseline scores of 8 parts per million (ppm) of each gas. There was an increase of 85 ppm over baseline to 101 ppm. As the increase was over 33 ppm, this was considered severe bacterial overgrowth of the small intestine. Per the provider note dated 4/3/17, she presented with gas and bloating and a low vitamin D level. She was started on Xifaxan 200 mg three times daily for 28 days.  The patient has requested reimbursement for Xifaxan 200 mg tablets administered on 4/10/17 and 4/19/17. The Health Insurer has denied the request for reimbursement and reported that it was not medically necessary for treatment of this patients medical condition. This denial is the subject of this appeal and determination.Xifaxan has been proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief (Scarpellini, et al; Gatta, et al). For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo (Scarpellini, et al). The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones (Pimentel, et al; Lauritano, et al).  Results were sustained for several weeks after treatment. A recent study by Boltin and colleagues has corroborated this finding. A prospective trial of patients, with irritable bowel syndrome and a positive breath test, found that 86% responded to Xifaxan, and symptoms were reduced as well (Moraru, et al). The dose and duration of 600 mg per day for 28 days are consistent with regimens used in studies (Gatta, et al).  Therefore, Xifaxan 200 mg on 4/10/17 and 4/19/17 were medically necessary for the treatment of this patients small intestinal bacterial overgrowth. For the reasons stated above, the medication at issue was 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 patient is a 26-year-old female with a history of an intensive care unit admission for alcoholic ketoacidosis. She had a history of depression and anxiety with poor compliance with medication. The physician reviewer found that based on the records, this patient met American Society of Addiction Medicine (ASAM) criteria for sub-acute substance abuse rehabilitation (ASAM 3.5) provided from 6/20/21 through 7/18/21. The ASAM criteria focuses on six dimensions to determine the appropriate level of care. 

For dimension 1, acute intoxication or withdrawal potential, the patient had several episodes of withdrawal and experienced alcoholic ketoacidosis, alcohol hepatocyte injury, macrocytic anemia and physical withdrawal. After discharge from the inpatient hospital, she was stable enough to receive further medical detoxification at the level 3.5 residential treatment level of care.

For dimension 2, biomedical conditions, the patientas medical problems as cited in dimension 1 were stable enough to be treated at the 3.5 level of care.

For dimension 3, emotional, behavioral, or cognitive conditions, the patient had a history of anxiety and depression and had difficulty complying with medication on an outpatient basis. Her co-occurring anxiety and depression and need for supervision of medications meets ASAM 3.5 level of care criteria.

For dimension 4, readiness to change, the patient was ambivalent about residential treatment and thought it was ajust what her family wanteda, showing low insight and poor judgment and supporting the need for further structured treatment to enhance her willingness to change.

For dimension 5, relapse, continued use, continued problem potential, the patient had tried stopping on her own several times and had developed serious medical problems which could worsen and be potentially fatal outside of a structured 24-hour monitored treatment setting.  

For dimension 6, recovery environment, the patientas family works in the wine business and she would have been exposed to continuous use had she been discharged to her motheras home. The patient had no support for sobriety at her home in Colorado. She met 3.5 level of care on dimension 6.

Accordingly, sub-acute substance abuse rehabilitation (ASAM 3.5) provided from 6/20/21 through 7/18/21 was medically necessary for the treatment of this patient
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


The parent of an 11-year-old male enrollee has requested reimbursement for the Prometheus Anser IFX test performed on 7/16/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.   The physician reviewer found that on the current peer-reviewed medical literature, the Anser IFX test is used as part of standard of therapy in patients who treated with infliximab to determine whether a patient is benefiting from the drug or if they need an increased dose. The information received from this test may lead to a shortened interval or increased dose or possibly change of medication. The Anser IFX test helps to inform the provider whether the serum levels of drug are in the range to be beneficial and effective or if a patient has antibodies that could potentially lead to a reaction, failure to respond. This can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication. This can not only prevent the patient from having a flare but save them from potential side effects of a drug they may not benefit from. In this case, the patient was on infliximab but started having rectal bleeding. Thus, the Anser IFX testing performed on 7/16/14 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 58-year-old female who presented in August 2019 with back pain. The patient has requested authorization and coverage for CT of thorax, abdomen and pelvis. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that the requested CT scan of the abdomen/pelvis is not indicated. In this patientas case, there has not been any involvement in the soft tissues below the diaphragm. The records also fail to demonstrate the medical necessity of the requested CT scan of the thorax. Much has been written concerning the appropriate schedule for imaging follow-up of lung cancer. However, many of these studies have referenced lung cancer that is not as advanced as in this patient. For instance, the National Comprehensive Cancer Network (NCCN) recommends for stage I and stage II that CT scans be obtained every three to six months for three years, and then every six months for two years, and then annually thereafter. These recommendations, however, were made for patients after definitive therapy, where a cure is suspected. For more advanced stages of non-small cell lung cancer, the NCCN guidelines are less precise, and indicate that imaging should be individualized. The American Society of Clinical Oncologists has also established guidelines for surveillance scanning following treatment for lung cancer. However, their guidelines are similarly established for curative-intent therapy, not for advanced stage IV disease. Their guidelines are similar to the NCCN guidelines. Schneider points out in his summary, aathere are insufficient data to support different surveillance strategies based on disease stage in patients not actively receiving cancer-directed therapy, including stage III non-small cell lung cancer and stage I-III small cell lung cancer. Although more frequent imaging may detect asymptomatic recurrences earlier, this does not translate into a survival benefit in the available studies. As a basic concept, imaging is only indicated when it will affect patient management. In this particular patient, with moderate improvement and no significant acute symptoms, it is likely unnecessary to obtain imaging at such frequent intervals. As with any tumor, changes are not likely to happen rapidly, and it is often more advantageous to have comparison studies performed at wider intervals. For this patient, scans every three months are likely too frequent. If the referring physician is considering altering her therapy, then a follow-up CT scan of the chest may be warranted at the six-month interval. In order to better evaluate the bone metastases, the CT scan is likely not the most optimal study. Therefore, the requested CT of thorax, abdomen and pelvis is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 70-year-old male enrollee has requested reimbursement for service code 97139, unlisted therapeutic procedure, performed on 4/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient presented with complaints of grade 5-7/10 low back pain radiating into the right buttock, posterior thigh, and anterior lower leg. Symptoms were aggravated by walking and relieved by sitting. Functional limitations were noted in activities of daily living. He had failed to improve with previous conservative treatment, including nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and chiropractic care. He underwent 38 sessions of the novel IntraDiscNutrosis therapy from 4/20/20 to 6/24/20. Under consideration is a request for reimbursement of this therapy, billed using the unspecified CPT code 97139. Literature available on the chiropractic provideras website indicated that this therapy consisted of whole body vibration, Pettibon wobble chair, disc oscillation therapy (North American Medical Device), and a soft back brace. There is a lack of current evidence-based medical literature to support this therapy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the use of these procedures for this patient. There is no compelling rationale to support this combination of physical medicine care in an extensive therapy protocol over any available standard therapy. Therefore, the unlisted therapeutic procedure provided on 4/20/20 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for OxyContin provided from 7/23/15 through 9/22/15. The Health Insurer has denied this request indicating that the medication at issue was 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 medication at issue in this patients case.  The current medical evidence does not support the use of OxyContin in this clinical setting.  The records do not show that non-opioid treatment options have been exhausted.  The records have not documented behavior therapy for pain, despite research to support its use.  Therefore, OxyContin provided from 7/23/15 through 9/22/15 was not medically indicated for the treatment of this patient.  Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female who has experienced two episodes of unexplained syncope in the setting of homozygous genetic markers for early repolarization syndrome (ERS) associated with a risk of sudden cardiac death. She is noted to have two brothers who have implantable cardioverter-defibrillator (ICD) for protection from sudden cardiac death (SCD) in the setting of ERS. One brother experienced an aborted episode of SCD due to ventricular fibrillation which was effectively treated by an ICD. Physical examinations were noted to be unremarkable. There is also a family history of syncope, sudden cardiac death, and genetic defect with the patient being homozygous for ERS in the setting of two episodes of syncope. The treating provider recommended ICD for protection from SCD. The Heath Insurer denied the request for cardiovascular defibrillator as investigational for treatment of this patient. This patient has a strong family history of SCD and has been documented to be homozygous for ERS by genetic testing and poses as a high risk for SCD. The risk stratification of these patients is problematic in that electrophysiology studies were not conclusive and the baseline electrocardiogram did not demonstrate ERS findings, which may be unmasked by exercise. In the review by Zakka and Marwan, patients who demonstrated to be genetically at risk for SCD would benefit from an ICD. While this patient has not been shown to have suffered an episode of SCD as the etiology for her recurrent syncopal episodes and has not been documented to have baseline ECG changes, there is sufficient documentation and supporting data to justify placement of the defibrillator. The placement of an ICD would likely be more beneficial than standard treatment which would consist of watchful waiting and possible implantable loop recorder (ILR) placement. In addition, the patient presents at a high risk for another episode. Moreover, the standard ILR is only capable of documenting, and not treating episodes of malignant arrhythmias. All told, the placement of cardiovascular defibrillator is likely to be more effective than the available standard options for treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator 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 50-year-old male enrollee has requested authorization and coverage for transcatheter insertion of permanent leadless implantable pacemaker. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has a history of pacemaker placement and a recent episode of syncope caused by imminent battery failure in the existing pacemaker. He was advised to have replacement with a leadless pacemaker.  The requested leadless pacemaker is standard of care and it decreases the risk of infections. Therefore, transcatheter insertion of permanent leadless implantable pacemaker is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This is a complex case in which a patient who was initially diagnosed with ulcerative colitis underwent colectomy with J-pouch.  Ultimately, she was found to have complicated pouch disease presumably because the underlying disease was, in fact, Crohns disease.  The patient was placed on maximal doses of Remicade and had a marginal response clinically. Remicade is the drug of choice for treatment.  In this clinical setting, it was medically reasonable to check drug and antibody levels.  Therefore, Anser IFX testing performed on 9/04/15 was likely to have been superior over other methods of 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: Medical Necessity
Decision: Overturned

Summary Reviewer 




The parent of a 17-year-old female enrollee has requested reimbursement for psychiatric residential treatment center services from 10/6/15 through 12/31/15. 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 that there is sufficient support for the services at issue in this clinical setting. Prior to RTC level of care, the patient tried and failed multiple different avenues of outpatient care and care at less restrictive levels. Her behaviors were escalating and had not abated with treatment at these less restrictive levels. The patient continued her adverse behaviors.  The behaviors had escalated to the point where she began abusing multiple different substances, exhibiting high risk behaviors, experiencing depression and suicidal ideation. She also exhibited a general lack of care for her present behaviors. The documentation noted that this patient was at serious risk of causing significant self-harm, whether intentional or accidental. The patient required continued supportive services with intensive individual, family and group therapies prior to being discharged into the community or at a lower level of care. As such, psychiatric RTC services from 10/6/15 through 12/31/15 were medically necessary for treatment of this patient. Therefore, for the reasons stated above, 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  
The patient is a 53-year-old female with a history of abdominal pain. The patient presented on 
3/6/23 for an evaluation of her recurrent abdominal pain radiating to her back, along with nausea, 
vomiting, and weight loss. The patient underwent the recommended CT scan on 3/8/23. The Health 
Insurer has denied the services at issue as not medically necessary for the evaluation of the patients 
medical condition. This denial is the subject of this appeal and determination. The physician 
reviewer found that according to the American College of Radiology (ACR) guidelines for the 
evaluation of patients with abdominal pain, a contrast-enhanced CT scan of the abdomen and 
pelvis is appropriate. Imaging plays a key role in this setting to help direct management and 
treatment. A CT scan of the abdomen and pelvis has been proven to improve the final diagnosis 
and management of patients presenting with abdominal pain. In this case, the patient presented 
with abdominal pain, nausea, and vomiting. A prior CT scan demonstrated colitis. The ACR 
guidelines indicate that a CT scan is appropriate in this setting. Therefore, the CT scan performed 
on 3/8/23 was medically necessary for the evaluation of the patient.