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

Summary Reviewer 


A 34-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance abuse residential treatment center (RTC) services provided from 9/25/16 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 alcohol dependence.   The physician reviewer found the documentation demonstrates the patient had few complaints as reported in the records provided for review as evidenced by the low CIWA scores of 1-2. The patient was not a danger to himself or others. He had no comorbid medical conditions except for the torn hip abductor for which he was awaiting surgical repair. He was anxious and had episodic depression. However, there were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the RTC level of care. He was psychiatrically stable to the extent that he did not need a 24-hour treatment at an RTC facility to render his care from 9/25/16 forward. No new problems had arisen and there was no evidence to indicate that returning him to a less restrictive treatment environment would lead to destabilization. He was internally motivated and the psychiatry notes on 9/19/16 indicate that he was participating in treatment. He had sober supports in place. As of 9/25/16, the patient did not meet the American Society of Addiction Medicine (ASAM) clinical guidelines for RTC level of care and could have been successfully treated at an ambulatory level of care such as partial hospitalization program (PHP) or intensive outpatient program (IOP). Thus, the RTC services provided from 9/25/16 forward were not and are not medically necessary for treatment of this patients alcohol dependence. Based on the foregoing discussion, 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a five-year-old male enrollee has requested reimbursement for albendazole provided on 3/01/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees medical condition.The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient does not have documented parasitic infection. There is some use of albendazole in children on the autistic spectrum that have gastrointestinal issues, but in the absence of positive cultures, this would be considered off-label usage and not consistent with the current standard of care. The medical evidence does not support the medication at issue in this clinical setting. Therefore, albendazole was not medically necessary in this patients case. Therefore, the medication 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: Overturned

Summary Reviewer 

The patient is a 38-year-old female with severe chronic pelvic pain. She underwent imaging of the pelvis, which showed dilated vessels, left larger than right. The physician reviewer found that this patient has clinical findings and imaging studies suggestive of pelvic congestion syndrome. There is limited data regarding the standard of care or optimal strategy to manage this diagnosis. For women with pelvic congestion syndrome, invasive treatment is an appropriate option. However, since randomized trials have not been performed, an optimal procedure is not known. As in this case, gonadal vein embolization is an accepted practice in the medical community. Case reports have shown the benefit of this procedure. The reported technical success rates of ovarian vein embolization range from 89 to 100 percent with clinical success rates of 58 to 100 percent (follow-up period of up to five years). Complication rates of 4 to 8 percent have been reported for ovarian vein embolization. Gonadal vein embolization is safe, well-tolerated, and allows for a minimally invasive approach. Thus, vascular embolization is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found based on the documentation submitted for review, there is a lack of sufficient rationale for the use of proton therapy in the palliative setting for the treatment of an orbital lesion. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for multiple myeloma. In addition, there is a lack of literature that compares clinical outcomes of proton beam radiotherapy compared to standard photon techniques for orbital metastases. The standard approach in this clinical setting is standard photon techniques. Also, the American Society of Radiation Oncology (ASTRO) emerging technology committee report on proton therapy does not mention the use of proton therapy for this condition (Allen, et al). A comparison of proton technique versus three-dimensional (3D) conformal technique has been submitted and reviewed against published and generally-accepted normal tissue constraints. The comparison shows no clinically relevant reduction in radiation doses with the proton plan compared to the standard intensity modulated plan. The doses that have been provided to show the difference between photon and proton plans are both within acceptable ranges. Although the 3D dose to certain critical structures may be higher, it is still considered an acceptable plan by Quantitative Analysis of Normal Tissue Effects in the Clinic (QUANTEC) dose criteria and the difference between the two plans is not considered clinically significant (Marks, et al). Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in this setting. Based on these reasons, proton beam therapy was not and is not likely to be more beneficial than standard treatment with photon techniques. Based upon the information set forth above, the services at issue were not and 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: Overturned

Summary Reviewer 

The parent of an eight-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found that in 2003, the U.S. Food and Drug Administration (FDA) approved the use of growth hormone therapy for idiopathic short stature or non-growth hormone-deficient short stature defined as height standard deviation less than or equal to -2.25 or less than or equal to 1.2nd percentile or age and gender. This patient meets the criteria for idiopathic short stature and has shown good response to growth hormone treatment with adequate monitoring and minimal side effects. She also had a poor pre-treatment growth velocity and poor final height prediction, which is greater than two standard deviations below the mid-parental height. Continued growth hormone therapy is medically appropriate in this clinical setting. Thus, Nutropin AQ Nuspin is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 54-year-old male enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) performed on 6/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short-term to intermediate-term outcomes for localized prostate cancer. There is a paucity of controlled trials available for analysis, and a lack long-term survival data is available. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or HIFU that these interventions are not standard care options because comparative outcome evidence is lacking. Therefore, HIFU provided on 6/28/16 was not likely to have been of greater benefit than other treatment options. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 43-year-old female enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) therapy from 10/23/15 through 11/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.   The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. The patient began TMS therapy on 8/21/15 with a PHQ9 of 27/27, indicating a severe level of depression. Over the course of TMS treatment, the documentation noted that her depression lifted, as reflected by her subsequent PHQ9 scores and subjective reports. By 10/23/15, she reported significant improvement with a PHQ9 of 5/27. On 10/7/15, she received TMS session #30, and on 10/28/15 she received TMS session #6 of tapering.   The documentation noted that the Health Insurer had approved 30 TMS sessions with an additional six for tapering. The sessions from 10/23/15 through 10/28/15 were medically necessary, as she showed improvement while in active treatment. However, the services from 10/29/15 through 11/24/15 were not medically necessary for treatment. There is a lack of evidence, in the body of literature, to support the medical necessity of continued long term TMS treatment, in this patients case. As such, the TMS sessions from 10/23/15 through 10/28/15 were medically necessary but not thereafter. Therefore, for the reasons stated above, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 35-year-old male enrollee has requested reimbursement for substance abuse residential treatment from 6/17/15 through 7/03/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  This patient had a concerning history of alcohol use that began in late adolescence.  His drinking was dominating multiple functional domains, impaired his sociability and relationships, and resulted in an arrest with subsequent probation.  He lacked insight into the extent of his addiction as he thought he could resume drinking alcohol.  Thus, 11 days of residential treatment was an insufficient duration of treatment to address the patients convoluted relationship with alcohol and mobilize the meaningful therapeutic momentum needed to foster sustained sobriety.  In the absence of residential programming, the patient would have more than likely returned to a pathological and self-defeating pattern of alcohol consumption.  The comprehensive services were delivered in accordance with an individual treatment plan.  Further, the services were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  The placement facilitated active treatment and also provided opportunity to further explore and treat his anxiety, which was identified as a trigger for his drinking.  Finally, the duration of services was consistent with community practice standards.  All told, substance abuse residential treatment services provided from 6/17/15 through 7/03/15 were 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: Upheld

Summary Reviewer 2

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that calprotectin, when measured in feces, is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease (IBD). Fecal calprotectin may also be useful to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse (Burri and Beglinger). While one time fecal calprotectin testing may have clinical utility, a series of calprotectin assays does not (Bourdillon, et al). In this case, the patient underwent a total of nine serial testing of fecal calprotectin from 12/7/15 through 12/26/16. This serial testing has not proven adequately correlative with the patients other inflammatory markers. For the reasons provided, the assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was not and is 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 and is 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  
The patient is a 52-year-old female with a history of cervical dystonia and secondary cervicogenic 
headaches. The patient received Xeomin injections on 12/23/22. The Health Insurer denied the 
treatment 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 
according to the recent American Academy of Neurology (AAN) practice guidelines, botulinum 
toxin is accepted as first-line treatment for patients with cervical dystonia. Xeomin is a preparation 
of botulinum toxin approved by the U.S. Food and Drug Administration (FDA). Per the AAN 
guidelines, Xeomin is likely safe and effective for the treatment of patients with cervical dystonia. 
In this case, the patient had a history of cervical dystonia with secondary cervicogenic headaches. 
The patient had tried several treatment options, including include indomethacin, oxycodone, 
Zanaflex, Advil, Nurtec, left C3-5 facet injections, dry needling, and trigger point injections. 
Xeomin is accepted as a first-line treatment option for this patients condition. Therefore, the 
Xeomin injections received on 12/23/22 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 48-year-old female enrollee has requested reimbursement for lab testing (Factor V Leiden genetic testing) provided on 12/16/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although there is an increased risk of a thrombotic event with hormone use, in the population as a whole the overall risk of a thrombotic event is still small. This low risk to the general population is especially true if women with known risk factors are pulled from the general population and screened. Currently, given these facts, the current recommendations suggest that only those with specific risk factors should be screened. The documentation submitted for review does not demonstrate that the patient has had a venous thrombosis, pulmonary embolism, family histories, or adverse pregnancy events. All told, the testing at issue was not likely to be superior for evaluation of the patients medical condition than other modalities.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue such as this patient. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and overall increase in diagnostic accuracy compared to two-dimensional imaging alone. The medical evidence supports the service at issue in this clinical setting. All told, breast tomosynthesis performed on 3/15/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service 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: Upheld

Summary Reviewer 

The representative of a deceased female enrollee has requested reimbursement for inpatient services provided from 8/17/17 through 9/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of cirrhosis of the liver. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. There is limited records to support an inpatient admission as of 8/17/17. The patient had stabilized as of 8/15/17. She did not require high-flow oxygen and was hemodynamically stable. She was working with therapy and did not have active infections. Her mental status was described as waxing and waning with mild confusion, which was expected for her medical condition. The laboratory studies were stable, with a stable hemoglobin, and she was tolerating oral medications. There was no documentation of active bleeding or respiratory distress. The records do not demonstrate that the patient required ongoing inpatient care during the dates of service in dispute. All told, inpatient services provided from 8/17/17 through 9/11/17 were not medically necessary 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: Experimental
Decision: Overturned

Summary Reviewer 3

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that the gene testing performed to gauge risk for thyroid cancer on 2/16/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cytopathology of the 1.9 cm thyroid nodule was consistent with AUS. The risk of malignancy is 5-15% in AUS (Cibas, et al; Haugen, et al). The risk of malignancy decreases to less than 6% with benign findings by gene expression classifier (Haugen, et al; Alexander, et al). In this case, the patients thyroid nodule was enlarged with suspicious features, such as size, it is hypoechoic and has intranodal vascularity. It is one among other nodules, which had not enlarged significantly. In this clinical setting gene testing was appropriate to determine whether to perform a diagnostic hemithyroidectomy or an oncological thyroidectomy, if the result were suspicious. Therefore, the testing at issue has been established as 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 50-year-old male has requested authorization and coverage for the LINX Reflux Management System.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found the LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux symptoms despite maximal medical therapy for the treatment of reflux.  In this patients case, he has acid reflux as based on pH recording.  However, the records document that he has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory when compliant with daily acid blocker drug use.  Also, implantation of LINX in this setting must be approached with caution given his documented complaints of globus.  Therefore, the requested LINX Reflux Management System is not likely to be of greater benefit than other treatment options.  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.