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

Summary Reviewer 2

The patient is a 44-year-old female who has had bilateral breast cancer. In addition, she has also had non-Hodgkins lymphoma and mucoepidermoid cancer. She has a strong family history of cancer, with a sister with lymphoma, sister with thyroid cancer and a paternal grandmother with uterine cancer. There are other members of the family with thyroid cancer. In November 2016, her blood was submitted for the MyRisk genetic susceptibility panel.  The patient has requested reimbursement for gene testing performed on 11/28/16.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. BRCA testing guidelines recommend BRCA testing for this patient as she was diagnosed with breast cancer at the age of 42.  However, at issue is the MyRisk panel, which is a 25 gene panel that includes BRCA within it, but also a variety of other suspected risk genes. Although many of these gene mutations are of real interest and are being actively studied, for the most part they have as yet not been found to be significant or predictive enough to be the basis for clinical decisions by the carriers or their family members. Such panel testing is not included in the guidelines from major organizations. Thus, gene testing performed on 11/28/16 was not likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 15-year-old male with a history of short stature. Per the submitted documentation, he underwent growth hormone stimulation testing in 2010, which showed that he was sufficient in growth hormone production. In March 2016, the predicted adult height was calculated to be 62.5 with the chronological age of 12 years and bone age of 12 years 6 months. The mid-parental height is 68.5. The records noted pretreatment growth velocity of 4.8 cm per year, which was low.  He was started on growth hormone therapy on 5/11/16 due to growth failure or low growth velocity and poor height prediction. The patients parent has requested coverage for Nutropin AQ. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation supports the medical necessity of the requested medication. The U.S. Food and Drug Administration has approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile for age and gender. This patient had improvement in growth velocity to 7.6 cm per year. This patient meets the criteria for idiopathic short stature. He was prescribed growth hormone therapy and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. The medical evidence supports the requested medication in this clinical setting. Thus, Nutropin AQ is medically necessary for the treatment of this patient. Therefore, the requested medication is 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 39-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that this patient has obstructive sleep apnea and nasal obstruction. He had procedures to relieve the nasal obstruction and has continued to be unable to tolerate the CPAP device. The patient had a drug induced sleep endoscopy which showed anterior-posterior collapse. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. This patient is a candidate for the device given his body mass index (BMI) is less than 32 and he has failed CPAP therapy and nasal surgery. In sum, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be superior over other available 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 39-year-old female who underwent anterior cruciate ligament (ACL) reconstruction on 4/12/21.  The patient has requested authorization and coverage for knee arthroscopy (CPT codes 29856, 29875 and 29884). The Health Insurer has denied this request and reported that the requested services 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 fails to demonstrate the medical necessity of the requested services. In this case, the treating provider is requesting arthroscopic surgery with multiple codes for the treatment of continued pain after ACL reconstruction. The examination does not demonstrate any consistent objective findings that indicate ongoing internal derangement. The MRI shows no evidence of anterior scarring, which can cause pain with full extension after ACL reconstruction. The anterior cyclops lesion is a well-known surgical indication for postoperative ACL range of motion loss; however, it is not present in this case. Anterior knee pain can be an expected complication after the reconstruction surgery in some patients. Therefore, the requested for knee arthroscopy (CPT codes 29856, 29875 and 29884) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 12-year-old male enrollee has requested authorization and coverage for a Lupron injection. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient started puberty after the age of 11 years old, which is a normal age of puberty. This patient does not have precocious puberty. Per the records, he had a bone age of 13 years 6 months with a height of 152.9 cm. This gives him an estimated adult predicted height of 68.9 inches, which is well above the mid-parental height of 64 inches and within normal range for an adult male. Treatment with Lupron is not indicated for preservation of height. Mood changes are common among children who undergo pubertal changes, and it is a physiologic stage of development. Mood changes during puberty are not an indication for Lupron therapy. The puberty in males is completed when the bone age is 16 years of age. This patient has advanced bone age, but there is no indication of rapid bone advancement over time at this time. This patient can have up to 2.5 years left to grow. Therefore, the requested Lupron injection is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 53-year-old male enrollee has requested authorization and coverage for Otezla 30 mg tablets. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.  The physician reviewer found there is a lack of medical studies that demonstrate Otezla prevents joint injury on patients with erosive psoriatic disease. Moreover, while the diagnosis of psoriatic arthritis was documented in the provided records, there was inadequate symptomatology, a lack of radiologic studies and a lack of physical examination findings to support this diagnosis in this patient. Therefore, for the reasons stated above, 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: Upheld

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for an endoskeletal left transtibial prosthesis provided on 1/03/19. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of outcomes data available from controlled clinical trials published in the peer-reviewed literature to substantiate the safety and marginal effectiveness of microprocessor-controlled ankle-foot prosthetic componentry over designs lacking microprocessor aid. The available data are from small pilot studies, which, on balance, have not demonstrated clinically significant advantages of these components over conventional ankle foot components. A small study by Agrawal and colleagues noted no significant differences in work between microprocessor-controlled devices and conventional devices in individuals with an amputation when negotiating stairs.  Bai and colleagues noted potential for improvements with negotiation of slopes using a prosthesis with a microprocessor-controlled ankle-foot, but there were no demonstrated differences in comparison to a conventional ankle-foot mechanism that were statistically significant. Overall, there are no proven clinical or functional advantages of this type of componentry that would offset their heavier weights and significantly increased bulk. In addition, concerns related to potential adverse effects on the socket-limb interface have been raised. It is also unclear what happens if the electronics on this type of prosthetic componentry fails, either due to mechanical failure or battery power loss. Therefore, the endoskeletal left transtibial prosthesis provided on 1/03/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 22-year-old female enrollee has requested authorization and coverage for spine nerve treatment, procedure codes 64634 and 64633. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Manchikanti and colleagues discuss the effectiveness of medial branch blocks in systematic reviews and randomized trials. Thoracic spine was noted to have evidence with controlled blocks Level II-1, moderate to strong evidence lasting from months to a year with level II-2 to II-3. Thoracic facet joint nerve blocks showed improvement in 71% of the patients at 6 months, 76% at 12 months, 71% at 24 months, and 69% at 36 months. Thus, the requested services are successful in treating lumbar spine pain in repeated fashion. In this case, given she has had successful cervical and thoracic rhizotomies in the past, the requested services are 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested authorization and coverage for Botox injections.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the patient has been documented to have migraine, and is stated to have chronic migraine.  Chronic migraine is most easily described as patients with migraines, with headache more days than not (greater than 15 days per month).  Botox has been confirmed to be beneficial for chronic migraine, but studies of episodic migraine have not documented benefit.  In this case, the patients headache frequency is not documented.  Thus, chronic migraine cannot be confirmed, and the requested Botox injections are not medically indicated for the treatment of this patient.  Therefore, the requested services are 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 

A 47-year-old female enrollee has requested reimbursement for radiofrequency ablation performed on 2/21/19. 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 the current medical evidence supports the services at issue in this clinical setting. Liver directed therapy has been part of oncologic surgical programs for many years. It is a safe procedure with excellent data supporting local control and cure for certain types of tumors. Microwave ablation is comparable to the old systems of radiofrequency and has improved local control, more uniform cell death and decreased ablation times with no increased morbidity. Long-term control and local recurrence is significantly better with lesions less than 3 cm. The majority of data for ablation has been reported for primary liver tumors or common metastatic tumor types (such as colorectal and neuroendocrine), but there is data to support treatment in the setting of gynecologic malignancies, with excellent local control and a survival advantage. This patient had multiple prior procedures, and each subsequent operation can be more difficult, with increased morbidity. Ablation offers excellent local control in a minimally invasion fashion. The patient recovered expeditiously and had an excellent result on post procedure MRI. She received standard of care for isolated recurrence of her ovarian cancer. Therefore, radiofrequency ablation performed on 2/21/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 63-year-old male with thymic carcinoma. He initially presented in November 2014 with dyspnea. A computed tomography scan showed an anterior mediastinal mass, which was biopsied. The pathology showed this was a thymic carcinoma. He had surgical resection in May 2015. The mass involved the left upper lung lobe, pericardium, parietal and visceral pleura, and diaphragmatic and mediastinal lymph nodes. He received four cycles of chemotherapy and radiotherapy. The patient has minimal residual disease. The tumor was submitted for mutational testing. The patient has requested reimbursement for FoundationOne testing performed on 12/28/16. The Health Insurer denied this request on the basis that the services at issue were investigational for the evaluation of this patients medical condition. There is support for the efficacy of the services at issue in this clinical setting. This patient was diagnosed with a very rare tumor, thymic carcinoma, which is metastatic.  Combination chemotherapy had induced a significant response but with progressive disease FoundationOne testing was the next step. A study of 86 patients by Von Hoff and colleagues of 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 had very significant results for patients with stage IV tumors. Therefore, the molecular profiling such as with FoundationOne testing performed on 12/28/16 was likely to have been more beneficial than any available standard therapy for evaluating the patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been 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 parent of a 16-year-old female enrollee has requested reimbursement for residential treatment center (RTC) services provided from 7/20/16 through 8/24/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder. The physician reviewer found that the records provided for review do not support the medical necessity of the RTC services provided from 7/20/16 through 8/24/16 for treatment of this patients medical condition. The patient did not require 24-hour supervision in a highly restricted setting to manage her anorexia and depression safely. According to the America Psychiatric Association (APA), the patients medication management could have been safely and adequately conducted in a less restrictive treatment setting. All told, the RTC services provided from 7/20/16 through 8/24/16 were not medically necessary for treatment of this patients eating disorder. Based on the foregoing discussion, 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 


A 38-year-old female enrollee has requested authorization and coverage for autologous chondrocyte transplant. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has had persistent and progressively worsening right knee pain and swelling. Significant functional difficulty is documented in activities of daily living and recreational/work activities. Clinical examination findings are consistent with imaging evidence of full thickness grade IV chondral defects of the medial femoral condyle and trochlea and genu varum. She is status post arthroscopic chondroplasty, loose body removal and cartilage biopsy on 9/13/17. There is no specific evidence in current peer-reviewed literature limiting the use of autologous cultured chondrocytes to a single lesion, although the risk factor for failure increases with lesion size and complexity. Given the young age of this patient, significant functional difficulty, and size of the lesions, the use of autologous chondrocyte transplant for the medial femoral condyle lesion and trochlear lesion is reasonable to allow potential delay of total knee replacement which would likely be the next definitive treatment. Therefore, the requested autologous chondrocyte transplant is medically necessary for the 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 3

A 54-year-old male enrollee has requested authorization and coverage for neurostimulator electrode array and pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient meets clinical criteria for consideration of surgical management of his obstructive sleep apnea symptoms. He has undergone prior drug induced sleep endoscopy which documented the location of obstruction with anterior posterior but no concentric collapse at the tongue base.   The patient had trialed continuous positive airway pressure therapy, but was intolerant of the use of these devices. Clinical studies of the use of hypoglossal nerve stimulation suggested that the patients only benefit from this device with a body mass index less than 32, and this patient meets this criteria. Boon and colleagues noted that selective upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment. Woodson and colleagues noted long-term improvements with upper airway stimulation and demonstrated that adverse events were uncommon. There is sufficient support for the requested services in this clinical setting. Thus, CPT codes 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the brain and cervical spine performed on 9/04/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees multiple sclerosis. The physician reviewer found that although no definite current imaging guidelines are available for imaging in multiple sclerosis, the following recommendations are based on current literature and clinical practice. If multiple sclerosis is suspected, MRI of the brain with and without contrast as well as cervical and thoracic spinal cord is indicated as a baseline examination. If a diagnosis of multiple sclerosis is made, then follow-up imaging of the brain and possibly spinal cord (depending on initial imaging results) is recommended three to six months after starting disease modifying treatment. If the diagnosis is unclear and thought to be a clinically isolated syndrome, not definitively multiple sclerosis, then the patient can be imaged with MRI of the brain and possibly spinal cord in one to three months, also depending on if the spinal cord was initially affected. Imaging thereafter is then approximately every six to 12 months. In this case, the patient had initial brain and cervical/thoracic imaging in April 2018 and May 2018, respectively. As the initial spinal imaging was negative, follow-up spinal imaging was not medically necessary four months later, on 9/04/18. Per the medical evidence, follow-up MRI of the brain on 9/04/18 was medically necessary. In sum, MRI of the brain was medically necessary for the evaluation of this patient. The records fail to demonstrate the medical necessity of MRI of the cervical spine. Therefore, a portion of the services at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.