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

Summary Reviewer 3


A 63-year-old female enrollee has requested reimbursement for the Prolia injection performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found according to the documentation submitted for review, the patient presents with osteoporosis with a history of fracture and failure of an FDA approved therapy for osteoporosis. There is a substantial amount of medical evidence that supports Prolia as an appropriate treatment option in patients with osteoporosis. Prolia is FDA approved for the treatment of osteoporosis. For the reasons provided, the Prolia injection performed on 11/21/14 was 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 services at issue were 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 22-year-old male with a history of idiopathic scoliosis. He has had extensive chiropractic and acupuncture care from 10/13/15-7/4/16 of at least 36 visits. His diagnoses are cervical and thoracic sprain, rib sprain, and muscle spasm. His treatment includes chiropractic manipulation, traction, and electrical stimulation, abdominal and low back exercises as well as acupuncture. He initially had severe pain but from 6/13/16 to 8/8/16, his condition was unchanged and his pain was consistently at 2/10. He had 10 acupuncture sessions from 4/29/16 to 6/4/16 and another 14 sessions from 6/13/16 to 8/8/16. The patient has requested reimbursement for the acupuncture services provided from 6/13/16 through 8/13/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Acupuncture is not statistically different than sham acupuncture or other forms of treatment for chronic neck pain (Zhang, et al; White, et al). Thus, acupuncture is not considered medically superior to other standard available forms of treatment. The patient also did not improve during the entire time he was receiving acupuncture. Accordingly, the acupuncture treatments provided from 6/13/16 through 8/13/16 were not medically necessary for treatment of this patients idiopathic scoliosis. 

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 69-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis without contrast material, followed by contrast material and further sequences (CPT 72197). The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees rising prostate specific antigen (PSA) levels.  The physician reviewer found that the American Urological Association (AUA) guidelines do not advocate the use of multiparametric MRI as a routine screening tool for prostate cancer. However, the current medical literature has demonstrated that in certain patients, multiparametric MRI offers an advantage not afforded by transrectal ultrasound (TRUS) guided biopsy. Such is the case for this patient. The patients steady rise of PSA with tripling of the value over three years is a concern for prostate cancer. The literature reports that there can be significant risk with TRUS guided biopsy with significant false negatives since the cores are randomly obtained. The use of multiparametric MRI allows the stratification of risk for aggressive tumor and compares more favorably to random biopsies. This patient is at risk for prostate cancer due to steadily rising PSA. Thus, for this particular patient, the requested multiparametric MRI is medically necessary for further evaluation of his medical condition. Based on the foregoing discussion, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 47-year-old male enrollee has requested authorization and coverage for ultralightweight wheelchair. The Health Insurer has denied this request and reported that the requested equipment is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the available records indicate that the patient has been diagnosed with hypokalemic periodic paralysis.  Periodic paralyses are rare neuromuscular disorders that typically present clinically with intermittent focal or generalized muscle weakness, often precipitated by triggers, including alterations in serum potassium levels. The records otherwise indicate that extensive diagnostic testing and follow up at a neurology clinic has not revealed evidence of myotonic disease, motor neuron disease, myopathy, Kennedys disease, mononeuropathy, myopathy, myotonic dystrophy or other condition. The wheelchair has been recommended for the patients functional issues. The physical examinations and functional evaluations that are documented in the available records, however, have not shown functional impairments that would preclude the patient from accomplishing his mobility-related activities of daily living. Notably, the most recently documented gait examination in the available records showed a narrow based gait with a normal arm swing and normal stride. Functionally, while the patient is experiencing fatigue and near falls, there are no objective indications that he is unable to accomplish his mobility-related activities of daily living without the proposed ultralight manual wheelchair. It is reported, moreover, that he may be undergoing surgeries for his shoulders in the near future, which may potentially preclude him for operating the proposed wheelchair altogether for an indefinite period of time. The submitted records fail to demonstrate the medical necessity of the requested device. Therefore, the requested ultralightweight wheelchair is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.  The physician reviewer found that the patient is a 58-year-old male who was diagnosed with prostate cancer on 10/18/17. At that time, he was found to have a Gleason 3+4=7 adenocarcinoma in four of 12 cores. The patient has requested reimbursement for Oncotype DX Prostate Cancer Assay performed on 11/13/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. There currently are three major options for the management of localized prostate cancer. These include surgery, various forms of radiation therapy, and active surveillance. Recommendations as to these options are based on risk stratification, which estimates the risk of the future development of progressive cancer. Various features of an individuals cancer are put into this assessment, particularly the prostate-specific antigen (PSA) level, clinical stage, and pathologic details of the cancer. A further refinement of such prognostics is the use of gene panels, such as Oncotype DX Prostate Cancer Assay. This is a 17-gene panel that may assist in predicting recurrence after treatment for prostate cancer. There is sufficient support for the services at issue in this clinical setting. Therefore, Oncotype DX Prostate Cancer Assay performed on 11/13/17 was 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 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 

A 58-year-old male enrollee has requested reimbursement for knee arthroscopy performed on 8/27/19. 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 there is a lack of support for the services at issue in this clinical setting. The Health Insurer covered the arthroscopy with partial medial meniscectomy and chondroplasty, but did not cover the synovectomy as there was no documentation of rheumatoid arthritis, pigmented villonodular synovitis, or other condition necessitating the synovectomy. In reviewing the medical literature pertaining to performing synovectomy for mild osteoarthritis, although it is supported in rheumatoid arthritis or pigmented villonodular synovitis, debridement of the synovium in mild osteoarthritis is not supported. As such, performance of synovectomy in this case was not medically necessary. Therefore, CPT 29876 provided on 8/27/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 62-year-old male enrollee has requested authorization and coverage for sacroiliac joint (SI) fusion/percutaneous spine fusion. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees SI joint disorder. The physician reviewer found that A review of current peer-reviewed literature and evidence based medical guidelines demonstrates a lack of strong evidence supporting the efficacy of sacroiliac joint fusion in this patients case. Shaffrey and Smith concluded that there was insufficient high-quality evidence regarding surgical management of SI joint pathology to support the role of SI joint fusion in the management of chronic lower back pain.  Zaidi and colleagues found that surgical intervention for SI joint pain was beneficial in a subset of patients but evidence for the efficacy of SI joint fusion was lacking. They recommended that serious consideration of the cause of pain and alternative treatments should be given before performing an SI joint fusion. For these reasons, the requested procedure is 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 procedure 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 27-year-old male enrollee has requested reimbursement for the pneumatic compressor or deep vein thrombosis (DVT) system provided from 4/5/16 through 5/4/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees left knee with patellar tendon rupture, anterior cruciate ligament (ACL) rupture, medial cruciate ligament (MCL) injury and medial meniscus injury. The physician reviewer found that in the peer-reviewed medical literature, Kakkos and colleagues concluded that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted. This patient underwent left knee arthroscopic surgery for ACL reconstruction on 4/5/16. He was prescribed an intermittent pneumatic compression device for mechanical DVT prophylactic therapy from 4/5/16 to 5/4/16. 

There are limited DVT risk factors identified for this patient. DVT risk factors included undergoing arthroscopic surgery, length of surgery, and obesity with a body mass index (BMI) of 30.4. It is noted that the patient was a current every day smoker. However, there is no documentation that anticoagulation therapy would be contraindicated, or standard compression stockings insufficient, to warrant the use of mechanical prophylaxis. Therefore, the pneumatic compressor or DVT system provided from 4/5/16 through 5/4/16 was 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 equipment at issue was 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 20-year-old male enrollee has requested authorization and coverage for inpatient admission for lidocaine infusions for seven days. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees orthostatic headache. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient presents with new onset of daily headache with a positional component that has been extensively and appropriately evaluated. He has had aggressive therapy, including a blood patch, given the positional component and strong suspicion for idiopathic intracranial hypotension. Subsequently the diagnosis has been changed to chronic migraine. The issue in this case is the proper characterization of the patients headache disorder. His headache has features of intracranial hypotension due to the significant postural component, features of new daily persistent headache due to the clear onset and near constant nature of the headache, as well as chronic migraine. However, the therapy for all of these headache disorders is different. Intravenous lidocaine has a long history of use, but with minimal support in the peer-reviewed literature. For the patients current diagnosis of chronic migraine, treatment with Botox has an excellent track record in refractory patients. In addition, topiramate and Depakote are two other therapies that are commonly used in chronic migraine, and have double blind placebo controlled studies to support their efficacy. In this clinical setting, treatment with Botox with one of the anticonvulsive therapies discussed is likely to be more beneficial for treatment of the patients medical condition than inpatient admission for lidocaine infusions. Based upon the information set forth above, the requested services are 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

Expedited Review A male enrollee has requested authorization and coverage for Praluent and Repatha. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hyperlipidemia and probable diagnosis of familial hypercholesterolemia. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Nature of Statutory Criteria/Case Summary: Repatha and Praluent are PCSK9 inhibitors approved only for patients with heterozygous familial hypercholesterolemia or documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not meet these criteria. Based on the records provided for review, the patient presents with hyperlipidemia and is intolerant of statins and Zetia. However, there is no documentation to support a history of homozygous familial hypercholesterolemia, heterozygous hypercholesterolemia, or atherosclerotic heart disease. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. For these reasons, the requested Praluent and Repatha are not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A enollee has requested authorization and coverage for a non-invasive electrical bone growth stimulator. The Health Plan has denied this request indicating the requested device is not medically necessary for treatment of the patients right foot pain. Review of the submitted documentation does not support the medical necessity of the requested non-invasive electrical bone growth stimulator. The patient underwent magnetic resonance imaging (MRI) of a painful right foot. The MRI revealed an intrinsic, non-displaced, irregular fracture at the proximal segment of the right hallux tibial sesamoid. The study was reviewed with the patient, and a non-invasive electrical bone stimulator was recommended. The patient has requested coverage for a non-invasive electrical bone growth stimulator. The Health Plan has denied this request and reported that the requested device is not medically necessary for the treatment of this patient. The Centers for Medicare and Medicaid Services indicates that a non-invasive electrical osteogenesis stimulator is covered only if any of the following criteria are met: (1) nonunion of a long bone fracture defined by radiographic evidence that includes two sets of x-rays with multiple views, 90 days apart, confirming fracture healing has ceased for 3 or more months before starting treatment with the osteogenesis stimulator, or (2) failed fusion of a joint, other than in the spine, where a minimum of 9 months has elapsed since the last surgery, or congenital pseudoarthrosis. Bone growth stimulators are authorized for use on a long bone fracture. In this case, the MRI of the patients foot showed a fracture of the tibial sesamoid bone. This patients provider has recommended a non-invasive bone growth stimulator for the tibial sesamoid fracture. The tibial sesamoid is a small bone below the first metatarsal head and is not considered a long bone. The medical evidence does not support the requested device in this clinical setting. Therefore, the requested non-invasive electrical bone growth stimulator is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in podiatric medicine and is actively practicing. The reviewer is an expert in the treatment of the patients medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An female enrollee has requested reimbursement for monitored anesthesia care. Findings:  The physician reviewer found that there is a lack of sufficient support in the medical literature for the services at issue in this clinical setting. The American Gastroenterological Association Institute (AGAI) noted that possible indications for an anesthesia specialist include patients with pregnancy, morbid obesity, neurologic or neuromuscular disorders, a history of alcohol or substance abuse, and patients who are uncooperative or delirious. AGAI also noted endoscopic procedures that may require an anesthesia specialist include endoscopic retrograde cholangiopancreatography (ERCP), stent placement in the upper GI tract, and complex therapeutic procedures. In this case, the patient presented without comorbidities for a standard endoscopic procedure that does would necessitate the use of a monitored anesthesia care. As such, the monitored anesthesia received was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vyvanse tablets.Findings: Lisdexamfetamine dimesylate (LDX), or brand name Vyvanse, is a medication within a newer class of long-acting agents for the treatment of attention deficit hyperactivity disorder (ADHD). These drugs are known as prodrugs and do not rely on mechanical release of active drug that may be affected by gastrointestinal (GI) factors such as transit time and pH. Unlike other stimulant medications that use a pH-dependent mechanical formulation (beads) to deliver active medication, LDX absorption and conversion are not affected by variations in gastric pH. Therefore, LDX is not prone to pH-mediated food or drug interactions. LDX was FDA approved for the treatment of adult ADHD in 2009. Its effects last for 14 hours in adults, and its safety and tolerability profile is similar to that of other stimulant medications. Several trials have demonstrated LDXs efficacy in treating ADHD in adults. Compared with other long-acting drugs indicated for ADHD, LDX is associated with lower daily average consumption, less need for augmentation, and greater persistence with therapy. The medication also has lower potential for abuse. In this case, the patient has ADHD, they are taking Vyvanse for an FDA approved diagnosis, and they have been stable for over a year. The patient also functions as an educator, and they pose a risk of decompensation and functional decline without this medication. Accordingly, the requested medication, Vyvanse tablets, is medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for the patient's medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.