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

Summary Reviewer 


I am board certified in psychiatry and I am actively practicing. I am 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. In addition, I hold a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review. I have no history of disciplinary action or sanctions against my license. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  During the dates of service in dispute, both her mood and behavioral problems had improved. Per the records, she was medically stable, following directions, taking medication, and did not have aggressive, suicidal, or disruptive behaviors.  She did not exhibit active suicidal ideations. She had a greatly reduced incidence of purging, although she did continue to have some restricting and purging behaviors. The intensity of her symptoms could have reasonably been treated at a less invasive level of care.  All told, mental health intensive outpatient services from 11/03/15 through 12/24/15 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 46-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) with computer aided detection performed on 11/10/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of left breast ductal carcinoma in situ. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Breast MRI has an important role in both screening and diagnostic settings.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  In some studies, the specificity of breast MRI has been reported to be as low as 37%.  There is a lack of evidence to support the use of MRI as a surveillance tool rather than conventional mammography.  Concerning DCIS, there is considerable literature which suggests that the term carcinoma should be dropped when describing these changes.  Often, DCIS is characterized as stage 0, or a pre-cancerous condition.  The National Comprehensive Cancer Network (NCCN) has recommended routine follow-up physical examinations and regular follow-up mammography for surveillance following a diagnosis of DCIS.  The NCCN does not recommend follow-up surveillance MRI.  In this case, there has been no submitted information which would warrant routine use of MRI for this patient.  All told, breast MRI with computer aided detection performed on 11/10/15 was not medically indicated for the evaluation of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 41-year-old male enrollee has requested reimbursement for elastase pancreatic fecal and fecal calprotectin laboratory testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the records do not document the superior effectiveness of the services at issue. Fecal calprotectin is a useful test as a quantitative measure of inflammation within the gastrointestinal tract. It is useful to distinguish patients with irritable bowel syndrome versus inflammatory bowel disease and can allow patients to avoid unnecessary colonoscopy. However, this patient underwent this test the year before, and the records do not demonstrate the need to repeat this test. In sum, fecal calprotectin laboratory testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The patient is a 58-year-old male with chronic hepatitis C virus, genotype 1b. The documentation submitted for review indicates he has early stage disease. Fibrospect II testing on 2/13/14 revealed a Metavir score of F0-F1. The patients provider recommends treatment with Viekira Pak. Thus, the patient is requesting authorization and coverage for Viekira Pak. The Health Insurer has denied the requested medication as not medically necessary. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Denying treatment for patients with early stage hepatitis C is not supported by the peer-reviewed literature. Thus, the recommendation is not deny patients treatment if they have early stage disease, but to provide treatment to avoid complications from advanced disease, including liver failure and extrahepatic complications. AASLD/IDSA guidelines recommend Viekira Pak, a daily fixed-dose combination of paritaprevir (150 mg)/ritonavir (100 mg)/ombitasvir (25 mg) plus twice-daily dosed dasabuvir (250 mg) for 12 weeks for treatment-naive patients with HCV genotype 1 infection. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 15-year-old male enrollee has requested reimbursement for residential mental health treatment services provided from 5/9/15 through 8/7/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and parent-child relational problem.  

 The physician reviewer found that the documentation provided for review does not support the medical necessity of residential mental health treatment services provided from 5/9/15 through 8/7/15. There is no evidence that treatment in a less restrictive setting would have been ineffective to manage the patient, since this had not been given an adequate trial. Similarly, there is a lack of objective evidence that continuation with a lesser intensity of care could not have provided improvement or prevention of deterioration. The patients level of symptomatology did not justify residential services. No suicidal ideations or homicidal ideations had been documented, but in one incident, which was assessed as an attempt to manipulate the staff. The patient was able to contract for safety and no additional intervention occurred. Further, continued residential services, especially at the highly intensive levels that were used, may have led to service dependency, which would be an adverse outcome. Therefore, this patient would have been more appropriately managed at a less restrictive, less intrusive intensity of services, such as outpatient care. For these reasons, the residential mental health treatment services provided from 5/9/15 through 8/7/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the medical literature supports the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues reported that integrated two-dimensional and three-dimensional mammography improve breast cancer detection and has the potential to reduce false positive recalls.  In sum, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  Therefore, breast tomosynthesis performed on 7/29/15 was likely to have been of greater benefit than other modalities.  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: Experimental
Decision: Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for DecisionDX Melanoma gene expression assay performed on 12/23/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found the prognosis of cutaneous melanoma has classically been determined by the staging system as documented by Balch and colleagues. Mitotic index has also been thought to add a bit more to the prognostics. By Balch tables, this patients melanoma would be classified as a T1a melanoma, or stage 1A. By these determinations, this patient has an excellent prognosis. DecisionDX is a study of 31 genes in the melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 97% disease free rate at five years) versus Class 2 (with a 31% disease free rate at five years). The study by Gerami and colleagues reported on 217 cases with good correlation between prognosis and DecisionDx classification, in patients undergoing sentinel node biopsy. However, it is not clear as yet how DecisionDx data compares to the ten year data of the Balch determinations, and whether it can be used to make clinical practice decisions. This is the issue presented in this patient with her pathologic findings and excellent prognosis. Moreover, National Comprehensive Cancer Network (NCCN) guidelines recognize that there is interest in these newer genetic profiles, but as yet only in the context of a clinical trial. In sum, DecisionDX melanoma gene expression assay performed on 12/23/15 was not likely be of greater clinical benefit than standard tests for the evaluation of this patient. Based on the information 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 37-year-old female enrollee has requested reimbursement for the Afirma thyroid fine needle aspiration (FNA) analysis provided on 1/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pituitary tumor and elevated prolactin.  The physician reviewer found that 
the National Comprehensive Cancer Network (NCCN) indicated that genetic profiling for atypia of unknown significance is a category 2b recommendation. In the medical literature, Duick and colleagues reported that obtaining a gene expression classifier in patients with cytologically indeterminate nodules is associated with a striking reduction in the rate of diagnostic thyroidectomy. Thus, in conjunction with peer-reviewed literature, the Afirma thyroid analysis performed on 1/15/15 was likely to have been more beneficial for thorough evaluation of this patients condition than any available testing. 
Based upon the information set forth above, I have determined 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma.  The physician reviewer found that the current medical literature supports the use of bronchial thermoplasty in patients with severe persistent asthma that has not responded to adequate trials of medical therapy. The use of bronchial thermoplasty in well selected patients has resulted in reduced exacerbations, fewer emergency department visits, and improved quality of life. All told, the scientific data supports the safety and effectiveness of the requested bronchial thermoplasty as likely to be more beneficial for this patients medical condition than treatment with any available standard therapy. Based upon the information set forth above, I have determined the requested procedure is 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the U.S. Food and Drug Administration (FDA) approved the LINX reflux management system for lower esophageal sphincter (LES) augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. This patient meets these criteria. A recent study comparing the LINX procedure with laparoscopic fundoplication found that GERD 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 (Reynolds, et al). Given these findings, the requested LINX reflux management system lower esophageal sphincter augmentation is 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 service is 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 parent of a 15-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 1/29/18 through 12/05/18. 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 that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. With regards to risk of harm, the records support a score of 2. The patient not actively suicidal, but she had a history of suicidal ideation. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to chronic mental illness, but overall showed appropriate daily functioning including school progress in treatment and prior to treatment at the residential treatment center. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems and did not have a recent history of substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The progress notes document that her relationship and family sessions were productive and were not adversarial. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents are involved in treatment on a regular basis and appeared to understand her needs. In terms of resiliency and treatment history, the records support a score of 3. It appears that the patient had response to her stay in the residential treatment center prior to her readmission for the disputed dates of service. She was participating in therapy programming and was not displaying seriously disruptive behaviors on a regular basis. It was noted that she had intermittent behavioral issues, but these were infrequent in nature. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlated with outpatient services. In sum, residential mental health treatment for children and adolescents provided from 1/29/18 through 12/05/18 was 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: Upheld

Summary Reviewer 2


A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested services in this patients case.  A review of the current literature pertaining to artificial disc replacement adjacent to a fused level indicates results superior to anterior cervical discectomy and fusion.  In particular, due to preservation of the motion, adjacent segment disease may be minimized.  The current medical evidence supports the recommended cervical artificial disc replacement in this clinical setting.  Therefore, the requested cervical artificial disc replacement is likely to be more effective than other treatment alternatives.  Based upon the information set forth above, the requested services are 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 11/27/20. 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 FoundationOne assay is one of many multi-genomic assays used in the hope of identifying a target at which a specific chemotherapeutic agent can be aimed. Thus far, there is a lack of convincing evidence that choosing an agent by such an assay is reliably beneficial or better than choosing an agent in more conventional ways. A randomized study by Le Tourneau failed to demonstrate benefit from such use of an assay-directed therapy. The percentage of patients who will benefit from such an approach appears to be quite small. One use of Foundation One assay is to identify tumors that are microsatellite unstable, and/or with high tumor mutational burden. Such tumors are sensitive to treatment with Keytruda. In this case, there was a previous FoundationOne assay in 2015 that indeed did identify the tumor cells as fitting into this category. There was no need to repeat the FoundationOne assay in 2020. Therefore, FoundationOne CDx testing performed on 11/27/20 was not likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 23-year-old female with a history of limited cutaneous systemic sclerosis, Raynauds phenomenon, mild skin tightness, arthritis and gastrointestinal disease. Per the provider, the patient has been treated with sildenafil since 2010 with good results. On 11/20/17, she presented for follow-up. She was to have repeat pulmonary function testing given her worsening shortening of breath and follow-up with subspecialty providers. She continued to have mild depigmentation in her anterior shins, increased dilated blood vessels at the medial ankle, Raynauds at fingers and cold feet. The patients therapies included hydroxychloroquine, methotrexate, pantoprazole, calcium/vitamin D, inhalers and sildenafil. Examination demonstrated mild sclerodactyly, dilated purple ankle vessels at the left ankle, right fourth finger periungual dilation, light tan ill-defined patches on both shins, and multiple blue dilated vessels on left lateral thigh. The plan is to increase sildenafil to, follow-up with gastroenterology, continue Plaquenil, and consider hematology consultation for possible iron infusion. Prior treatment has included nifedipine, Imuran, methotrexate, Rituximab, and Dynacirc without improvement, as well as minocycline. Pulmonary function testing on 12/31/14 showed restrictive chest wall disease, with potential airway disease and an increase in resistance. Echocardiogram on 6/29/16 showed a normal left and right ventricle and systolic function, with no significant change from previous study on 6/26/15. The patient has requested authorization and coverage for sildenafil 20 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary. For the treatment of secondary Raynauds phenomenon, the treatment of choice is a calcium channel blocker. Second-line treatment is typically a phosphodiesterase inhibitor (PDE-5). Roustit and colleagues concluded that PDE-5 inhibitors appear to have significant but moderate efficacy in secondary Raynauds phenomenon. Thompson and colleagues reported that PDE-5 medications are able to reduce episodes by 0.5/day which is comparable to calcium channel blockers (CCB) reduction by 0.6/day. In this case, the patient has failed multiple medications to include methotrexate, Imuran, CCB, Dynacirc, and Rituximab. The medical records demonstrate response with sildenafil. All told, the requested sildenafil 20 mg tablets is supported as medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.