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

Summary Reviewer 2

A 31-year-old female enrollee has requested reimbursement for osteochondral knee autograft CPT code 27416 performed on 3/7/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who had injured her left knee. The physician reviewer found that cartilage grafts and/or transplantations remain controversial. Systematic reviews have yet to demonstrate the superiority of OATS over the more standard procedures in this clinical setting. The aim of the OATS technique is to slow down the development of osteoarthritis. There is some scientific evidence of effectiveness for patients with a singular, traumatically caused grade III or IV femoral condyle deficit who are under 40 years of age and have an active lifestyle. However, the available evidence from individually published case series is not sufficient to permit definitive conclusions concerning the effectiveness of the OATS procedure. Therefore, osteochondral knee autograft, CPT code 27416 performed on 3/7/17 was not likely to have been superior over the other treatment options available to this patient. Based upon the information set forth above, the services at issue were 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 3

A 63-year-old female enrollee has requested reimbursement for unlisted laboratory services provided on 7/02/19 and 1/28/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient had a standard therapeutic approach for the treatment of multiple myeloma.  A new advance in the care of myeloma has been the analysis of minimal residual disease (MRD) by next generation sequencing. The test that is being used here is the ClonoSEQ testing. According to the National Comprehensive Cancer Network guidelines, the identification of the myeloma clone can be done at the time of diagnosis and also followed up during surveillance. The discussion within the National Comprehensive Cancer Network group and the current guidelines state, aMRD has been identified as an important prognostic factor. A prospective study of patients with newly diagnosed multiple myeloma evaluated MRD bone marrow samples and showed that had a median follow-up of 57 months MRD negativity after autologous stem cell transplant translated to significantly improved progression free survival and overall survival rates.a  Based on the current medical evidence, the testing as ordered was appropriate for this patient. Therefore, unlisted laboratory services provided on 7/02/19 and 1/28/20 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 28-year-old female enrollee has requested reimbursement and prospective authorization and 
coverage for ketamine infusions from 9/07/21 forward. The Health Insurer has denied this 
request and reported that the services at issue were and are investigational for the treatment of 
the enrollees medical condition. The physician reviewer found that there is sufficient support for 
the services at issue in this clinical setting. The patient has been diagnosed with major depressive 
disorder. Based on her failing at least two antidepressants plus psychotherapy, she qualifies for 
a  diagnosis  of  treatment-resistant  depression.  The  patient  has  tried  numerous  somatic 
treatments, such as transcranial magnetic stimulation and neurofeedback, still without remission 
of her depressive symptoms. In the course of her recent ketamine infusions, the patients 
depression lifted, as did her suicidality. Intravenous ketamine has been found to have a rapid and 
significant effect on depression and suicidality. Therefore, ketamine infusions from 9/07/21 
forward were and are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 43-year-old female enrollee has requested reimbursement for the screening digital breast tomosynthesis performed on 6/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 6/17/16 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 diagnostic procedure 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: Upheld

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for the Prometheus Anser ADA testing performed on 4/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that in this case, Anser ADA was recommended to direct the management of this patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient outcomes. In addition, the effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of antibodies and serum levels are retrospective or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). The study by Karmiris and colleagues found no direct relationship between trough serum Humira (adalimumab) concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. Given this lack of support, the Prometheus Anser ADA testing performed on 4/10/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 20-year-old female enrollee has requested reimbursement for unlisted procedure of the skin, mucous membrane and subcutaneous tissue (17999) performed on 11/26/18. 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. This patient has documented gender dysphoria. His gender dysphoria included dysphoria about breasts. Chest surgery in a transgender male has been shown to be an effective treatment for gender dysphoria. The World Professional Association for Transgender Health (WPATH) noted that sex reassignment surgery is effective and medically necessary. Per WPATH, criteria for mastectomy and creation of a male chest in transgender male patients includes persistent gender dysphoria, capacity for informed consent, age of majority, and medically and psychiatrically stable for surgery. This patient meets these criteria. Therefore, the unlisted procedure of the skin, mucous membrane and subcutaneous tissue (17999) performed on 11/26/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. There are no widely accepted clinical studies demonstrating that treatment strategies directed at advanced lipoprotein testing parameters will improve clinical outcomes in individuals with dyslipidemias. Clinical trial data to date does not support the superiority of measurement of such parameters beyond what is known from a basic lipid panel in assessing treatment. This was also the conclusion of the American College of Cardiology/American Heart Association 2013 guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Risk in Adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 53-year-old female enrollee has requested authorization and coverage for a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the standard of rehabilitative care in the setting of severe functional impairments due to central nervous system pathology such as stroke is to endeavor to address impairments, mitigate risks of complications, and to optimize overall function in all relevant domains with the assistance of services, such as physiatry, occupational therapy, orthotists, assistive technology providers, social workers, independent living counselors and vocational counselors, as appropriate. Increased independence can be pursued and achieved in this clinical setting using equipment such as assistive speech technology, smartphones, adaptive utensils, nonskid plates, gait/mobility implements, other adaptive equipment and accessibility/environmental modifications, if appropriate.  When there are limits to function despite exhausting more direct interventions, or when efficiency or safety calls for it, caregivers may be called upon to otherwise meet a personas functional needs. There is no proven role of the MyoPro elbow-wrist-hand-finger orthosis in question in stroke management or rehabilitation.  The proposed device does not replace the role of conventional (i.e., passive, light and custom-fitted) orthoses, which can be employed as needed to manage the effects of tone, to reinforce therapeutic positioning, and to enhance functionality when applicable. There are some potential functional benefits theoretically of the device in question, but these benefits have not been demonstrated in a clinically relevant setting. There is a lack of proven health benefits that can be attributed to use of this device.  The available scientific evidence related to the type of orthotic device in question is limited to preclinical work and anecdotal literature. The potential benefits, importantly, have not been demonstrated to outweigh the potential adverse sequelae and safety issues. This type of device could potentially cause or exacerbate edema, skin injuries, musculoskeletal injuries or pain. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested reimbursement for Harvoni. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found the submitted documentation supports the medical necessity of the medication at issue.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  The guidelines support Harvoni for treatment-naive patients with hepatitis C, genotype 1.  It is advantageous to treat patients at an earlier stage of liver fibrosis.  All told, Harvoni was medically indicated for the treatment of this patient.  Therefore, the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 43-year-old female enrollee has requested reimbursement for surgery performed by a non-participating provider on 6/15/17. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees back pain. The physician reviewer found that the documentation provided does not support the services at issue in this clinical setting. The patient has a foot drop and previous lumbar surgery with scarring. At the time of presentation on 6/15/17, the patient could have been safely treated by an in Plan spine provider. There was no indication for fusion surgery by a non-participating provider at that time. The medical records did not show any evidence of lumbar fracture, instability, or tumor that would have necessitated the procedure at issue. Additionally, the records indicated that the patient was approved for a consultation with an in Plan spine surgeon. As such, the criteria for surgery on 6/15/17 were not met and the patient did not need out of network spine surgery. In sum, surgery performed by a non-participating provider on 6/15/17 was not medically necessary for treatment of this patients medical condition.
Therefore, for the reasons stated above, 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 40-year-old female enrollee has requested authorization and coverage for Otezla 30 mg tablets, 60 per 30 days. 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 Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-TNF drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Otezla (apremilast) provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. ESTEEM 1 is the first phase III study confirming the efficacy of apremilast in psoriasis. Apremilast demonstrated significant improvements in mean percentage change in psoriasis area and severity index (PASI) score and in pruritus. PASI response was maintained over 52 weeks with continued apremilast treatment. In addition, apremilast demonstrated improvements in nail and scalp psoriasis, both difficult-to-treat forms of psoriasis. This patient has chronic plaque psoriasis that requires systemic treatment. The immunosuppressors and anti-TNF drugs can increase the risk for infection and malignancy. Otezla has been approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients. Therefore, Otezla, which does not increase the risk of malignancy and infection, is medically appropriate in this case. Thus, Otezla 30 mg tablets, 60 per 30 days, are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 66-year-old female enrollee has requested authorization and coverage for 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 enrolleeas obstructive sleep apnea. The physician reviewer found that the Inspire device has been approved by the FDA for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure therapy. However, a meta-analysis by Kompelli and colleagues found that contemporary hypoglossal nerve stimulation research consisted of single-arm clinical trials and case series, with a high likelihood of publication bias and a lack of comparative trials of hypoglossal nerve stimulation versus existing alternatives, such as upper airway surgery. They concluded that hypoglossal nerve stimulation amay not be the definitive choice for second-line therapya for obstructive sleep apnea. Overall, there is insufficient high-quality, peer-reviewed evidence to support the use of hypoglossal nerve stimulation over other available therapies. Therefore, Inspire upper airway stimulation system is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has been treated with intralesional steroids, topical steroids, as well as systemic steroids. His area of involvement has been as severe as alopecia totalis, which affects scalp, eyebrows, and eyelashes. He received treatment with Xeljanz in the past and did well. It was the best at keeping him in remission. As this patient did have a documented improvement in the past with Xeljanz, it is reasonable to continue with that treatment plan. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 12-year-old male with autism. The patients parent states that the patients therapy 
was terminated due to non-coverage, so no additional records are available. The patients parent 
has requested authorization and coverage for occupational therapy. The Health Insurer has denied 
the requested services as not medically necessary. This denial is the subject of this appeal and 
determination. The physician reviewer found that the current peer-reviewed medical literature 
supports the use of occupational therapy in the routine management of pediatric patients with 
autism (Houtrow, et al.). In addition, occupational therapy is known to be effective in improving 
functional outcomes for patients with autism with deficits as documented in this patients case 
(Schoen, et al.; Schaaf, et al.). Kashefimehr and colleagues noted that their findings support the 
effectiveness  of  occupational  therapy  with  a  sensory-integrated  approach  in  improving 
occupational  performance  in  pediatric  patients  with  autism  spectrum  disorders.  Moreover, 
occupational therapy is the most appropriate treatment modality to address the patients deficits. 
In this case, the patient started occupational therapy for the habilitative treatment of deficiencies 
associated with an autism spectrum disorder. Specifically, the patient has motor coordination 
problems and deficits in IADLs and ADLs, which are planned to be addressed with the requested 
occupational therapy. Therefore, the requested occupational therapy is medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested authorization and coverage for an insulin pump (T-Slim). 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 submitted documentation establishes the medical necessity of the requested services. In this case, the patient has a history of widely fluctuating blood glucose levels before meals, glycemic control that is suboptimal on a multi-dose insulin injection regimen, and variations in her daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to maintain glycemic control and prevent severe hypoglycemia. Several studies in the peer-reviewed literature have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes. Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, reduces the frequency of hypoglycemic events, and results in overall improved satisfaction in patients and their parents (Battelino; Plotnick, et al; Saha, et al). Finally, this patients caregivers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow-up plan on insulin pump therapy. Specifically, the patient and her family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have attempted to comply with dietary recommendations. Pump therapy is medically necessary for treatment of this patients diabetes. Furthermore, the patients previously prescribed OmniPod pump was never fully functional. Although there was no mechanical failure of the OmniPod and it is not out of warranty, in effect, the OmniPod malfunctioned in this patient after a trial of a few months, as the patient experienced significant adverse skin reactions at the sites of the adhesive tape, making it impossible for her to continue to wear the pump. In addition, due to the nature of her active lifestyle, the pump dislodged too often to make it a viable tool to deliver insulin, and her glycemic control worsened due to unpredictable insulin delivery. The T-Slim pump delivers insulin via a catheter inserted under the skin instead of a pod; the insertion site is much smaller and does not require as much adhesive tape to stay in place. In addition, the thin catheter in the T-Slim is less likely to dislodge with vigorous physical activity than the pod in the OmniPod system. Thus, transition to the T-Slim pump is medically necessary based on the history of adverse reaction to the OmniPod. Moreover, the T-Slim pump has been shown to have an easy-to-read screen and reduced error rates and training time compared to other insulin pumps (Schaeffer, et al). Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.