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

Summary Reviewer 




The parent of a 17-year-old female enrollee has requested reimbursement for the residential mental health treatment services provided from 1/21/15 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 issues. The physician reviewer found that the documentation provided for review does not support the medical necessity of the residential mental health treatment services provided from 1/21/15 through 12/31/15 for treatment of this patients medical condition. The patient did not appear to be at imminent risk of harm to self or others. The patients psychiatric issues prompting admission including depression and impulsivity could have been safely and efficiently treated at a less intensive setting. There also did not appear to be any acute impairment, behavior, or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and she was not at risk of undermining treatment at a less intensive level of care, such as outpatient care. All told, the patient did not require 24-hour supervision for the period of time at issue. Accordingly, the services at issue were not medically necessary. 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: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 22-year old female with a history of bipolar I, posttraumatic stress disorder, gender dysphoria, and an eating disorder. The record notes that the patient failed several medications and had four prior psychiatric hospitalizations. The patient is currently taking lamotrigine and lurasidone. The patient underwent genetic testing for medication guidance. The patient has requested reimbursement for genotype testing performed on 11/10/15.  The Health Insurer denied the request for reimbursement noting that the services at issue were investigational for the evaluation of this patient.  There is a lack of support in the medical literature for the use of genetic testing for medication guidance. A study by McIntye states, In some circumstances in clinical practice, phenotyping of cytochrome P450 enzymes may be relevant. However, sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available.  Other studies have found that genetic testing may not even be reporting relevant clinical information. There are some circumstances when genetic testing is done for safety reasons, like to test for possible Stevens Johnson syndrome or toxic epidermal necrolysis. However, there is a lack of head to head comparisons proving that genetic studies are of clinical benefit in this patients case. Currently, there is not enough evidence to show improved health outcomes due to genetic testing. In sum, genotype testing performed on 11/10/15 was not likely to have been more efficacious than the standard options for the evaluation of this patients medical condition. 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: Upheld

Summary Reviewer 


A 58-year-old male enrollee has requested reimbursement for Synvisc injection performed on 7/06/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees degenerative joint disease of the knee. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support the services at issue in this clinical setting.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  This patient has had multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.  There is also a risk of iatrogenic infection being introduced into the joint during the process of injection.  Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation.  The authors concluded after review of a total of 89 trials involving 12,667 adults that in patients with knee osteoarthritis viscosupplementation is associated with a small and clinically irrelevant benefit and there is an increased risk of serious adverse effects.  All told, Synvisc injection performed on 7/06/15 was 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 patient is a 58-year-old male with a history Wegeneras granulomatosis. The patient has requested authorization and coverage for Hizentra (immune globulin (human) subcutaneous solution preferred syringe 4 gm/20 ml). The physician reviewer found that the patientas clinical history, presentation and laboratory findings, including low level of immunoglobulin G level and poor antibody response to pneumococcal antibody, support the use of immunoglobulin replacement therapy. The current medical evidence supports subcutaneous immunoglobulin therapy in this clinical setting.  Therefore, Hizentra (immune globulin (human) subcutaneous solution preferred syringe 4 gm/20 ml) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 64-year-old female enrollee has requested reimbursement for CT of the thorax. 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 there is sufficient support for the services at issue in this clinical setting. Nontuberculous mycobacterial pulmonary infection can have various radiologic manifestations. These imaging findings include tree-in-bud opacities, bronchiectasis and ground glass opacities, most commonly in the right middle lobe and lingula. These findings are often not visualized on conventional chest radiographs and are best detected on chest CT. In this case, the patients initial abnormalities were not seen on prior radiographs but were subsequently seen on chest CT. Since the patient had a recurrence of symptoms status post antibiotic treatment, the best way to visualize this recurrence would be on chest CT, as her initial findings were below the detection of radiographs. The results of the CT scan affected the patients clinical management, prompting bronchoalveolar lavage as well as additional treatment. Therefore, CT of the thorax performed on 11/09/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 39-year-old male with stage III chronic kidney disease. He initially presented with 9-10 grams of proteinuria per day. He was treated with rituximab in August 2015. A renal biopsy in June 2016 demonstrated PLA2R+ membranous glomerulonephritis. The patient has subsequently been treated with mycophenolate. Proteinuria was recently measured at 8.1 grams per 24 hours. The patient has requested authorization and coverage for obinutuzumab (Gazyva) injections. The Health Insurer has denied this request indicating that the requested medication is considered investigational. Gazyva does not have U.S. Food and Drug Administration (FDA) approval for treatment of membranous glomerulonephritis. In addition, a review of published peer-reviewed medical literature indicates that there are insufficient data to support Gazyva as efficacious and safe for treatment of membranous glomerulonephritis. Standard therapy for membranous glomerulonephritis for which extensive data have been published includes the Ponticelli protocol with steroids and chlorambucil, Cytoxan, and calcineurin inhibitor therapy with cyclosporine or tacrolimus, which have not been tried in this patient. In a 10-year follow-up of one of the studies in membranous glomerulonephritis, treated patients using steroids and chlorambucil or Cytoxan had a higher likelihood of complete or partial remission with 88% versus 47% in the placebo group and a greater likelihood of surviving without renal failure 92% versus 60% (Ponticelli, et al). There is no documentation of a contraindication to any of these medications. In summary, the requested obinutuzumab (Gazyva) injections are not 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 medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 77-year-old female enrollee has requested reimbursement and prospective authorization and coverage for substance use inpatient rehabilitation from 7/11/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are 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.  There was no evidence of an acute psychiatric syndrome, grave disability or a medical crisis.  The patient had completed a safe detoxification.  She had a supportive spouse and safe housing.  Further, her relapse was prompted by a significant identifiable external stressor.  Prior to that, she was stable on an antidepressant medication and had sustained several months of sobriety in the absence of chemical dependency programming, such as community services, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization. This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. Thus, substance use inpatient rehabilitation from 7/11/16 forward were not and are not medically necessary for the treatment of this patient. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).  The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).   The physician reviewer found POTS may or may not be associated with autonomic neuropathy, characterized by an increased heart rate of 30 beats per minute with symptoms related to upright posture. Affected patients present with orthostatic intolerance, postural tachycardia, exercise intolerance, fatigue, dizziness and in some cases with other dysautonomic symptoms such as gastrointestinal or sudomotor dysfunction. In the peer-reviewed medical literature, Plash and colleagues concluded that diagnosis of POTS should consider orthostatic intolerance criteria and not be based solely on orthostatic tachycardia regardless of test used. Al-Shekhlee and colleagues compared two groups of patients retrospectively and noted a decreased sweat output on the quantitative sudomotor axon reflex test is the most frequent abnormal finding suggesting sympathetic cholinergic neuropathy. All told, the current scientific data supports the utility of autonomic testing in this diagnostic setting. Thus, the autonomic testing performed on 8/24/15 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: Overturned

Summary Reviewer 

The patient is a 53-year-old female who has a history of breast cancer, Helicobacter pylori infection, hyperlipidemia, hypertension, murmur, and obesity. The patient has requested reimbursement for 53 units of anesthesia services provided on 2/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The patient has morbid obesity, based on BMI over 35 kg/m2, with attendant health risks. According to the American Society of Anesthesiologists guideline for anesthesia care during endoscopic procedures, judgment of the need for monitored anesthesia care requires consideration of procedure requirements and potential risks. Wani and colleagues found higher risk for sedation-related complications with BMI over 30 and even higher with BMI over 35 during endoscopic procedures. Per the most recent American Society for Gastrointestinal Endoscopy guideline for sedation and anesthesia in endoscopy, elevated body mass index is an independent risk factor for hypoxemia during endoscopic procedures. In this patientas case, she had an extended procedure with both esophagogastroduodenoscopy and colonoscopy, and did not tolerate moderate sedation in the past. Based on current medical literature, this patient was at an increased risk for sedation-related complications. Therefore, 53 units of anesthesia services provided on 2/11/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 64-year-old female enrollee has requested authorization and coverage for an epidural steroid injection. 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 that the request for an epidural steroid injection is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient presents with chronic low back pain, and acute abdominal pain. The patient has stenosis at L4-5 without documented lower extremity pain, and negative for straight leg raise. The physical exam revealed no signs of radiculopathy including deep tendon reflexes or straight leg raise changes. Given the lack of documented signs and/or symptoms of radiculopathy, the requested services are not indicated for 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 


The parent of a 13-year-old female enrollee has requested reimbursement for residential treatment center services provided from 1/12/15 through 2/8/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the RTC services from 1/12/15 through 2/8/16 were medically necessary for treatment of the patients behavioral health conditions. During the treatment period in dispute, the patient worked through significant anxiety and behavioral dyscontrol through therapy, groups, dialectical behavior therapy (DBT) and medications. Based upon admission criteria by the American Academy of Child and Adolescent Psychiatry Level of Care Utilization System the patient scored a 26, indicating a need for 24-hour monitored care. In addition, the services provided were consistent and beneficial for treatment of the patients medical condition. For the reasons provided, the RTC level of care services provided from 1/12/15 through 2/8/16 were 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: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin 
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of 
the feet. The physician reviewer found that there is a paucity of medical literature suggesting that IVIG 
therapy is efficacious for the treatment of patients with small fiber neuropathy (Zeidman, et al.; Devigili, 
et al.). In one study by Gibbons and colleagues, the authors demonstrated a lack of benefit from 
treatment with IVIG in patients with small fiber neuropathy. The records provided for review indicate 
that this patient presents with a history of small fiber neuropathy and significant paresthesia of the feet. 
Per the provider, the patient has tried and failed numerous medications, including Effexor, Elavil, Lyrica, 
Cymbalta, gabapentin, meloxicam, mexiletine, and topical lidocaine. Overall, there is a lack of medical 
evidence suggesting that IVIG is a superior treatment option to the medications already tried and failed 
by the patient. Therefore, the requested Panzyga (immune globulin (Human)-ifas) is not likely to be 
more beneficial for the treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 26-year-old male who sustained a traumatic spinal cord injury in a motor vehicle 
accident. On 7/14/22, the patient was transported by air ambulance from the hospital in San Diego 
to a specialized rehabilitation hospital in Englewood, Colorado. The Health Insurer has denied the 
services at issue as 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 Air 
medical  transport  is  considered  medically  necessary  when  the  patients  condition  is  life-
threatening such that any form of transportation other than an ambulance would be medically 
contraindicated, the time needed to transport by ground poses a threat to the patients survival, and 
the patient is transported to the nearest hospital with appropriate facilities for treatment. When 
transferring a patient from one hospital to another, the air medical transport criteria must be met, 
and the initial hospital must not have the required services and facilities available to treat the 
patient. In this case, the patient sustained a traumatic spinal cord injury following a motor vehicle 
accident and reported no sensation or motor function in his bilateral lower extremities. After the 
initial hospital in San Diego, California provided all the care it could, the patient was transported 
by air ambulance to the nearest specialized rehabilitation hospital in Englewood, Colorado. 
Overall, the patient met the criteria for air ambulance transportation. The transferring hospital was 
not capable of providing specialized inpatient spinal cord rehabilitation services, and the receiving 
hospital was over 1,000 miles away. Given these findings, the air ambulance services performed 
on 7/14/22 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 62-year-old male who was diagnosed with glioblastoma in February 2018. The patient has requested authorization and coverage for Verzenio (abemaciclib tablets 200 mg). 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 this patient with recurrent glioblastoma has received multiple combinations of treatment in the recent past. Abemaciclib (Verzenio) is not U.S. Food and Drug Administration (FDA) approved for the treatment of glioblastoma and is not supported for off-label use by major drug compendia. The medical literature shows efficacy in animal models and potential for efficacy in patients with recurrent disease, but does not support use as a standard of care as a single agent or in combination with other drugs. In this patients case, it is possible that his stable disease is due to the use of immunotherapy and not abemaciclib, which he had been off for a period of time. Therefore, Verzenio (abemaciclib tablets 200 mg) is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 47-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 and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that obstructive sleep apnea is an increasingly prevalent clinical problem with significant effects on both personal and public health. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulation has been found to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. With a body mass index of 28.75 and apnea-hypopnea index of 25.5, this patient meets the criteria for implantation with a hypoglossal nerve stimulator. He has failed continuous positive airway pressure, which is the gold standard treatment for obstructive sleep apnea, and he is at risk for untoward cardiac sequelae of untreated obstructive sleep apnea. Therefore, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 52-year-old female enrollee has requested authorization and coverage for ablation of varicose veins. 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 that the medical necessity for ablation of varicose veins has not been established as medically necessary in this clinical setting. The Doppler report lacks a complete, anatomically detailed ultrasound report to ensure that there is junctional reflux in both of the GSVs, the right AAGSV, and left SSV. In the absence of a detailed ultrasound report, the requested services are not indicated for this patient. Based on the above, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.