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

Summary Reviewer 3


A 34-year-old female enrollee has requested authorization and coverage for BRCA testing. The Health Insurer has denied this request indicating that the requested testing is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the BRCA testing is important in clinical oncology because bilateral mastectomy would eliminate a carriers chance of developing breast cancer. At the present time genetic testing is not applied universally but rather to patients that exhibit family histories that are suggestive of inherited predispositions (U.S. Preventative Services Task Force; Frank, et al). A study by Frank and colleagues performed BRCA testing in 10,000 individuals and related the presence of mutations to the family history. The authors found that family history included at least one first or second degree relative with breast or ovarian cancer.  In this case, the patient does not have breast cancer but the best method for surveillance cannot be determined without knowing her BRCA mutation status. She has two second degree relatives with cancer, this history alone would not mandate magnetic resonance imaging (MRI) based breast cancer exams, but MRI would be indicated if she was found to be a BRCA mutation carrier. As such, BRCA testing is medically appropriate and likely to be more beneficial for evaluation of the patients medical condition than other modalities. Based upon the information set forth above, the requested testing is 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 authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees breast hypoplasia. The physician reviewer found that based on the medical documentation provided for this review, this patient has a significant congenital breast deformity associated with asymmetric breast hypoplasia. This is supported by the medical documentation from the patients plastic surgeon, endocrinologist and review of the photographs. She has undergone a work-up for correctable causes and no cause, other than a congenital condition, has been found. Her appearance would not be considered relatively normal appearing breasts for a female. The breasts are severely asymmetric and hypoplastic. Therefore, attempts to approximate a more normal appearance should be considered reconstructive and not cosmetic surgery. This is consistent with medically necessary, reconstructive surgery (Sadove and van Aalst; Seyfer, et al). Further, the requested procedure is consistent with the recommendations from the American Society of Plastic Surgeons (ASPS). The ASPS notes that breast reconstruction surgery to correct breast deformities, as well as surgery on the contralateral breast to achieve symmetry, are considered reconstructive surgery and, therefore, should be a covered benefit and reimbursed by third-party payers. Therefore, breast augmentation for this patient should be considered congenital breast reconstruction and is therefore medically necessary. Given these findings, requested authorization and coverage for mammoplasty, augmentation; with prosthetic implant (19325) and breast reconstruction with other technique (19366) are supported as medically necessary for treatment of this patients medical condition. 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 


A 44-year-old male enrollee has requested reimbursement for inpatient admission from 4/15/15 through 4/19/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition The physician reviewer found the current medical evidence supports the medical necessity of a portion of the services at issue.  In this case, the patella tendon reconstruction was carried out using allograft for patellar stabilization.  The MRI scan was performed on 4/14/15, so the diagnosis was known on 4/15/15.  The injury of 4/15/15 exacerbated pain, but no surgery was performed until 4/17/15.  In this clinical setting, two days of inpatient hospital stay was appropriate and medically necessary.  In this patients case, the diagnostic testing performed prior to surgery could have been performed as an outpatient. Therefore, hospitalization on the day of surgery and on the day after surgery, 4/17/15 through 4/18/15, were medically indicated.  The hospitalization prior to surgery was not.  As such, inpatient admission from 4/17/15 through 4/18/15 was medically necessary.  However, the records fail to demonstrate the medical necessity of the remaining dates of service at issue.  Therefore, I have determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 48-year-old male enrollee has requested reimbursement for Prometheus Anser IFX test performed on 8/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of ankylosing spondylitis and sacroilitis plus peripheral inflammatory arthritis. The physician reviewer found the medical literature does not support the superior efficacy of the services at issue in this clinical setting. The Prometheus Anser IFX is not currently routine testing that is performed when a patient has had flares of inflammatory arthritis while on Remicade. Current peer reviewed medical literature and evidence-based studies do not support the routine use of this test for management of inflammatory arthritis patients. On the basis of this lack of peer reviewed evidence, the Prometheus Anser IFX Test performed on 8/24/15 was not likely to be more effective than the available standard therapy for the evaluation of 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: Upheld

Summary Reviewer 

A 29-year-old male enrollee has requested reimbursement for custom foot orthoses/inserts (L3030-NU, LT, RT) that were ordered on 1/10/15. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that this patient presented status post a trip and fall injury on 1/4/15 with acute low back, mid-back and right hip pain and disability. Clinical exam findings were consistent with the reported diagnoses of lumbar radiculitis, lumbar/lumbosacral subluxation, thoracic sprain/strain, and pelvic, hip, and pubic subluxation. There was no evidence of a foot condition/deformity or leg length discrepancy. There was no radiographic or imaging evidence of spinal segmental instability. The patient reported a 10-30% reduction in symptoms and functional improvement over the initial week of care. There is no compelling documentation presented to support the medical necessity of custom made bilateral foot orthoses for this patient. Therefore, in the absence of evidence based medical guideline or peer-reviewed support, the custom foot orthoses/inserts (L3030-NU, LT, RT) were not medically necessary for treatment of the patients medical condition. Based on the above, the equipment at issue was 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 patient is a 53-year-old male with history of diabetes, hypertension and hyperlipidemia. The patient has requested reimbursement for inpatient stay provided from 7/26/19 through 7/29/19. 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 patient had progressive chest discomfort and an equivocal outpatient stress test. The plan for coronary angiography had already been determined. However, his symptoms progressed so he came to the emergency department and he was ruled out for myocardial infarction. The angiography plans were moved up, and he was admitted. Coronary angiography was indicated in this patient and doing it sooner than originally scheduled was medically appropriate. Although he did not have indicators for emergent angiography on the night of admission as his electrocardiogram was normal, his symptoms resolved and his troponins negative, he still required angiography and that was the medical plan. However, this did not occur until three days later on 7/29/19. There was no clinical reason stated for this relatively long delay of the planned diagnostic procedure, other than he presented on Friday evening and the catheterization was scheduled for Monday morning. If it was felt the patient was too high risk and could not go home to return Monday for the catheterization, then it could have been carried out the next day and the patient discharged thereafter as no obstructive disease was found. He did not rule in for myocardial infarction, his electrocardiogram was normal, he had no congestive heart failure or arrhythmia, his chest discomfort had resolved and the stress test was already completed, so he did not meet criteria for inpatient care. He met criteria for observation level of care with short stay based on both the initial clinical presentation and his clinical course. The inpatient stay was not medically necessary and observation level of care was appropriate. Therefore, inpatient stay provided from 7/26/19 through 7/29/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 63-year-old male who presented to his provider on 10/17/22. The records noted 
that a fusion magnetic resonance imaging (MRI) and biopsy of the prostate revealed intermediate 
risk Gleason score 3+4 cancer in five out of 15. The Health Insurer has denied this request and 
reported that the requested service is 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 supports the medical necessity of the requested service. HIFU is an 
established  alternative  to  cryotherapy  for  local  nonmetastatic  disease  that  is  established  as 
effective,  particularly  in  cases  of  radiation  failure.  Given  this  patients  potentially  locally 
controllable disease and the potential for good results with minimal side effects, the requested 
service is medically indicated. Therefore, HIFU is medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 64-year-old female who was transported by air ambulance from Brazil to Cedar Sinai Hospital (CSH) in Los Angeles, California on 1/18/20. The patient has requested reimbursement for air ambulance transport services provided on 1/18/20. 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 in order for air medical transport to be medically necessary, medical necessity criteria must be met. The patientas condition must be such any form of transportation other than ambulance would be medically contraindicated. Additionally, and the patientas  condition is such that time needed to transport by ground poses a threat to the patientas survival, and there is a medical condition that is life-threatening. Such conditions include, but are not limited to, intracranial bleeding, cardiogenic shock, major burns, conditions requiring hyperbaric oxygen, multiple severe injuries, transplants, limb-threatening trauma, or acute myocardial infarction requiring intervention, such as percutaneous transluminal coronary angioplasty. When transporting from one facility to another, the above criteria must be met and the first hospital must not have the required services and facilities to treat the patient. Further, when transferring from one hospital to another, the patient must be transported to the nearest hospital with appropriate facilities for treatment. This patient asserts that the facility she was admitted to in Brazil was not capable of providing appropriate care. Review of the available records indicates otherwise. The patient also states she required admission to a rehabilitation unit and there are no such facilities in Brazil. If such were the case, then transport would have needed to be to the closest facility capable of providing that care. Records do document that the patientas family had requested she be transferred to CSH in Los Angeles, California, to be closer to home and family. Therefore, air ambulance transport services provided on 1/18/20 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
 
The parent of a 16-year-old male enrollee has requested reimbursement for immunoassay for 
analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise 
specified and adalimumab on 8/6/21. The Health Insurer has denied this request indicating that the 
service and medication at issue were investigational for the treatment of the enrollees ulcerative 
colitis. The physician reviewer found that the patient has ulcerative colitis and was treated with 
Humira (adalimumab). The patient remained symptomatic with abdominal pain, bloody diarrhea, 
and weight loss. The provider sought to potentially switch the patient to a different therapeutic 
agent. The patient underwent bloodwork, including the testing for the presence of antibodies for 
adalimumab. There is a lack of data in well-designed, randomized controlled trials in current peer-
reviewed medical literature that supports this testing as safe and effective. The service at issue was 
not likely to have been superior to standard methods in the evaluation and management of 
ulcerative colitis including up-titrating the patients dose of Humira or switching to an alternative 
agent if there was concern regarding the efficacy of the medication. Therefore, immunoassay for 
analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise 
specified and adalimumab on 8/6/21 was not likely to have been more beneficial for treatment of 
the patient's condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 63-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System, CPT code 43284. 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 the U.S. Food and Drug Administration (FDA) has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. The device is a ring made up of a series of magnets that have sufficient attraction to increase the LES closure pressure, but allow for food passage with swallowing. Lipham and colleagues performed a prospective study that included 44 patients. The mean total percent time pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. A recent study by Reynolds and colleagues compared the LINX procedure with laparoscopic fundoplication. This was a retrospective study that used propensity matching to compare groups. The authors found that gastroesophageal reflux disease patients had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Five-year cohort data was recently published by Ganz and colleagues. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. Therefore, the LINX Reflux Management System (CPT 43284) is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement for residential mental health treatment provided from 1/28/15 through 3/21/15.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community settings optimize treatment gains.  In this patients case, she evidenced functional impairment from anxiety, mood symptoms and characterological influences.  Further complicating matters, this concerning confluence of pathology occurred in context of impulsivity and impaired family dynamics.  The patients illness burden was escalating despite outpatient services.  Based on the lack of significant clinical improvement, treatment at the time could not have reasonably been conducted in a setting less restrictive than the residential level of care while less intensive treatment would have resulted in inadequate care.  Moreover, the residential placement was recommended by a child psychiatrist following a failed attempt of outpatient treatment.  Thus, admission to the residential facility was safe, appropriate and consistent with good medical practice.  The services provided at the facility included trusted, evidence-based interventions that were indicated, such as dialectical behavior therapy, group therapy, family therapy and pharmacotherapy.  Finally, the services and setting were reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, residential mental health treatment provided from 1/28/15 through 3/21/15 was medically indicated for the treatment of this patient.  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 2 
A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets 
(30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested 
medication is considered investigational for the treatment of the insured's Chron's disease. 
The physician reviewer found that Rinvoq has been found to safely induce endoscopic remission 
in a significant proportion of patients with Chrons disease (Sandborn, et al.). Rinvoq has also been 
shown to improve quality-of-life and work productivity for patients with Chrons disease (Peyrin-
Biroulet, et al.). In this case, the patient has a history of Chrons disease since 2014. The patient 
has tried and failed treatment with biologics such as budesonide, high-dose infliximab with 
azathioprine, and high-dose Stelara with azathioprine. Rinvoq is the only treatment option that 
may be effective for the treatment of the patient, as no remaining treatment options are FDA-
approved for patients with Chrons disease. Therefore, the requested Rinvoq 45 mg tablets (30 
tablets every 30 days) are likely to be more beneficial for the treatment of the patients condition 
than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 29-year-old female enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing for methylenetetrahydrofolate reductase (MTHFR) and molecular pathology testing performed on 5/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for recurrent pregnancy loss. The physician reviewer found that inherited thrombophilias as cause for late term fetal demise have not been well demonstrated in the peer-reviewed medical literature. The American College of Obstetricians and Gynecologists (ACOG) does not support evaluating patients for a mutation in the MTHFR gene as a cause of fetal demise. Thus, the PCR testing for MTHFR and molecular pathology testing performed on 5/26/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested authorization and coverage for autologous cultured chondrocyte and autologous chondrocyte implantation of the knee. 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 in this case, the requested matrix autologous chondrocyte implantation (MACI) procedure is supported by the available literature for this patients condition. He has large unipolar chondral lesions of the weight-bearing portions of the distal femur with normal menisci. There are no noted arthritic changes on x-ray. He meets age criteria and has failed conservative management and a previous arthroscopic treatment.  His knee biomechanics and ligamentous stability is normal. The literature supports the use of this procedure for young patients with these types of lesions as second-line treatment, as they are not good candidates for arthroplasty due to their young age. Long-term results have been shown to be reasonable as far as outcome and durability. There is sufficient quality literature to support this procedure in patients that have failed first-line treatment. Thus, the requested autologous cultured chondrocyte and autologous chondrocyte implantation of the knee are likely to be more beneficial than other treatment options.