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

Summary Reviewer 1

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that pooled results of two large, randomized, placebo-controlled trials demonstrated that Botox is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine (Aurora, et al). Further, the U.S. Food and Drug Administration (FDA) approved Botox for headache prophylaxis in patients with chronic migraine with headaches on 15 or more days per month, each lasting more than four hours. To treat chronic migraine, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. The available medical records document the patient has failed at least two medications for migraine prophylaxis. In addition, the patients chronic migraine headaches occurred more than 15 days per month, lasting four or more hours, for at least three months. Given these findings, the Botox injections (CPT code 64615) provided on 5/26/17, 8/25/17, and 11/17/17 were 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: Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for Intracept procedure. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient has a history of chronic low back pain. There is no radicular pain in the lower extremities. MRI scan showed scoliosis and Modic type 2 changes in the vertebral endplates at L4-5. The provider has requested the Intracept procedure. This procedure was approved by the U.S. Food and Drug Administration in 2016 as a minimally invasive radiofrequency ablation of the basivertebral nerve. Studies have shown that this led to significant improvement of pain and function at three-months in patients with chronic vertebrogenic related low back pain. The procedure is useful in individuals with chronic low back pain not responding to treatment for six months who have evidence of Modic changes. Current literature suggests that degenerated or damaged vertebral endplates can cause chronic low back pain without evidence of radiculopathy. Vertebrogenic chronic low back pain is not adequately diagnosed and treated by other minimally invasive procedures. The procedure is safe and effective for Modic changes causing vertebrogenic low back pain. Therefore, the requested Intracept procedure is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The physician reviewer found that the medical records support a portion of the services at issue. The patient had borderline low B12 levels in April 2020. Testing for intermediates in vitamin B12 and folate metabolism (i.e., homocysteine) can be useful in cases in which initial test results for vitamin B12 are borderline. Because of potential inaccuracies in the measurement of vitamin B12 levels, the diagnosis can be confirmed by testing for methylmalonic acid (MMA) and homocysteine. In this case, testing for homocysteine on 6/10/20 was reasonable in order to confirm or exclude the diagnosis of vitamin B12 deficiency. However, there is a lack of support for repeat testing performed on 9/23/20, as this testing would have no bearing on the treatment plan and would not have changed the course of care. Therefore, homocysteine testing performed on 6/10/20 was likely to have been more beneficial than other methods of evaluating this patient. Homocysteine testing performed on 9/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 57-year-old male enrollee has requested reimbursement for CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that Transoral incisionless fundoplication is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference. In the trial by Trad and colleagues, 63 patients with gastroesophageal reflux disease refractory to proton pump inhibitor (PPI) therapy received transoral incisionless fundoplication versus maximum standard dose PPI therapy. At six months, both regurgitation and extraesophageal symptoms were eliminated in more transoral incisionless fundoplication than PPI patients (62 versus 5%); 90% of transoral incisionless fundoplication patients were off PPIs. After six months, all patients in the PPI (control) group elected to cross over to TIF. At three years, 90 and 88 percent of patients reported elimination of troublesome regurgitation and all atypical symptoms, respectively. At five years, 34 percent were on daily PPI therapy, and the average total gastroesophageal reflux disease health-related quality of life score improved from 22.2 (baseline) to 6.8. In a meta-analysis by Huang and colleagues of five randomized trials and 13 prospective studies, PPI use after transoral incisionless fundoplication increased over time; the satisfaction rate was only 69% at six months. In this case, the patient already underwent laparoscopy for repair of his hiatal hernia. The standard of care would have been to perform a laparoscopic fundoplication in that setting. Instead, a transoral incisionless fundoplication was performed, which has no significant advantage and likely has reduced durability compared to a surgical fundoplication. Therefore, CPT 43210 esophagogastroduodenoscopy with transoral incisionless fundoplication performed on 4/23/21 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

An 18-year-old female enrollee has requested authorization and coverage for Pentasa 500 mg. 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 there is a lack of support for Pentasa for the treatment of this patients Crohns disease. Pentasa (mesalamine) is a 5-aminosalicylic acid. According to American College of Gastroenterology guidelines for the treatment of Crohns disease, mesalamine is not recommended for induction of or maintenance of remission. The American College of Gastroenterology guidelines state, Oral mesalamine has not consistently been demonstrated to be effective compared with placebo for induction of remission and achieving mucosal healing in patients with active Crohns disease and should not be used to treat patients with active Crohns disease (strong recommendation), even for mild disease. The guidelines also note, Oral 5-aminosalicylic acid has not been demonstrated to be effective for maintenance of medically induced remission in patients with Crohns disease, and is not recommended for long-term treatment (strong recommendation). Akobeng and colleagues and Lim and colleagues performed reviews of the use of 5-aminosalicylic acid for induction of remission and maintenance of remission in patients with Crohns disease. The authors found that mesalamine is not superior to placebo for the treatment of Crohns disease, with sufficient evidence available during maintenance therapy indicating that further study is not justified. Therefore, Pentasa 500 mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 59-year-old male enrollee has requested reimbursement for right shoulder MRI 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 evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. In this clinical setting, an x-ray of the shoulder with appropriate views was likely to have been adequate to determine the treatment approach. There is a debate as to whether the MRI or ultrasound should be the next step. The ultrasound is felt to be more useful in the literature. Magnetic resonance arthrogram is the last step, if deemed necessary from the surgical viewpoint. In this case, there is no documentation of a thorough and detailed shoulder examination. X-rays have not been obtained. The MRI was requested when the patient became interested in a surgical solution to chronic pain. Chronic neck pain and extensive degenerative changes in the cervical spine have been mentioned which warrant a detailed cervical spine and neurological evaluation for radiculopathy. In the absence of documentation referencing the above, a request for MRI scan of the right shoulder is not supported by the literature. Therefore, the right shoulder MRI performed on 8/27/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 63-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System, CPT code 43284. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia, requiring endoscopic intervention. Sheu and Rattner concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current gastroesophageal reflux disease therapies, remains to be determined. Currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, the LINX Reflux Management System (CPT 43284) is not likely to be of greater benefit than other treatment options in this patients case.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 34-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the shoulder. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees shoulder pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There are multiple possible causes for traumatic shoulder pain, including pathology within the rotator cuff, glenohumeral joint, labrum or osseous structures. The initial imaging examination for the evaluation of traumatic shoulder pain is radiographs. Radiographs can detect unsuspected fracture or dislocation, arthritis, calcific tendinopathy or avascular necrosis. MRI is the next appropriate test for the evaluation of shoulder pain with normal radiographs when a rotator cuff disorder is suspected. MRI is highly accurate in the diagnosis of rotator cuff tendinosis and rotator cuff tears. Additionally, soft tissue detail is optimally depicted on MRI, such as tendon retraction, muscle atrophy and fatty infiltration. These findings can alter the course of management in the setting of rotator cuff injury. According to the American College of Radiology (ACR) appropriateness criteria for the evaluation of shoulder pain, radiographs are usually the appropriate initial imaging examination, followed by MRI, when rotator cuff or internal pathology is suspected. In this case, radiographs should be the initial test, prior to MRI. Thus, the requested MRI of the shoulder is not medically necessary for the evaluation of this patient. Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that fecal calprotectin, elaborated by neutrophils, is elevated when there is inflammation within the lumen of the gastrointestinal tract. In the setting of post-operative Crohns, a progressive rise is usually indicative of disease recurrence. Following serial measurements is a reasonably strategy rather than subjecting the patient to serial colonoscopy exams to assess disease activity. Performance of serial post-operative fecal calprotectin levels can be considered a standard of care strategy. Accordingly, the laboratory services (CPT code 83993) performed on 10/5/17 was 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 3


A 39-year-old male enrollee has requested reimbursement for the surgery performed on 9/22/15. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational for treatment of the enrollees degenerative disc disease (DDD) with herniations.  The physician reviewer found the current medical literature with regard to two level total disc replacement in the lumbar spine includes varying outcomes. In a recent article published by Trincat and colleagues, the authors noted that two-level lumbar disc replacement can improve spinal function while preserving its mobility but the procedure is fraught with risks and complications. Thus, longer follow-up is needed to evaluate the sustainability of the results and to detect any adjacent segment disease. A high-quality meta-analysis and health technology assessment concluded that there is insufficient evidence to draw extensive efficacy conclusions comparing artificial disc replacement with a broad range of recommended treatment options in the lumbar spine (Park, et al). All told, the efficacy remains uncertain and inadequate evidence exists to establish long-term benefits or safety. Thus, the surgery performed on 9/22/15 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 surgery 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 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that the medical evidence does not support the superior efficacy of the services at issue in this patients case. Ordering single nucleotide polymorphism (SNP) microarray analysis is not standard of care for patients with a diagnosis of schizophrenia, depression, or bipolar disorder. These disorders have complex genetics, and the current literature shows that the genetics of bipolar, depression, and schizophrenia are not fully understood. Moreover, there are many different genetic malformations that can lead to the same phenotype. Studies have found common genetic variants for those with bipolar disorder and schizophrenia, but many of these variants are not consistent. Diagnosing a patient with bipolar, schizophrenia, or depression based on SNP microarray analysis is not reliable and not standard of practice. Even if a patient were to have an abnormal SNP microarray analysis, these diagnoses are made by clinical evaluation and criteria. All told, cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and SNP variants for chromosomal abnormalities on 3/16/16 were not likely to have been more effective than the standard options for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The representative of a 63-year-old male enrollee has requested reimbursement for air and ground ambulance services provided on 10/21/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees transition to hospice care.  The physician reviewer found based on the medical literature and the presented clinical records submitted for review, the air and ground ambulance services provided on 10/21/16 were not medically necessary for treatment of the patients medical condition. Cholangiocarcinoma is a cancer originating from the biliary tract. In this case, prior to diagnosis the patient had multiple medical co-morbidities which limited his candidacy for systemic therapy. Due to an acute presentation of sepsis, a complication of a perforated duodenal ulcer, his medical status declined rapidly after his diagnosis. His provider estimated that the patients overall prognosis was weeks to months and therefore the patient requested transfer to Texas from California so that he could spend his remaining time with family. The patient was hemodynamically stable. The patient did not require a respirator. Although his condition was considered terminal, the clinical documentation does not support air transport as medically necessary. The patients medical status did not warrant transfer and similar hospice care options were available locally. Give the lack of medical necessity for transfer to Texas, the air and ground ambulance services provided on 10/21/16 were not medically necessary for treatment of the patients medical condition. 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: Overturned

Summary Reviewer  
 
The patient is a 64-year-old male who presented to his provider on 10/10/22. The patient has 
requested authorization and coverage for Botox (onabotulinumtoxinA for injectable 100 unit). 
The physician reviewer found that the submitted documentation supports the medical necessity 
of  the  requested  service.  Current  medical  literature  supports  the  use  of  botulinum  toxin 
injections for the treatment of hemifacial spasm, as medications for peripheral myoclonus are 
generally ineffective long-term and surgery is reserved only for extreme cases. Hallett and 
colleagues report that hemifacial spasm evidence supports a Level B recommendation for 
onabotulinumtoxinA. In a study that included 68 patients with hemifacial spasm, Sorgun and 
colleagues noted a 73.7% improvement with an average of 34.5 units, with less than 5% incidence 
of minor side effects. The authors concluded that Botox is an effective and safe treatment option 
for hemifacial spasm.  In a study on the clinical success and incidence of adverse events of 
repetitive botulinum toxin treatment of 15 years or greater, Czyz and colleagues reported an 
average treatment efficacy of 127 days using an average of 70.2 units of botulinum toxin. In this 
clinical setting, as current medical literature supports the use of onabotulinumtoxinA for the 
treatment of hemifacial spasm, and as it has been three months or more since the patients last 
treatment, the requested service is medically indicated. Therefore, Botox (onabotulinumtoxinA 
for injectable 100 unit) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 53-year-old female enrollee has requested authorization and coverage for arthroscopic hip surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees right hip pain.   The physician reviewer found that the records provided for review support the medical necessity for this patient to undergo the requested arthroscopic hip surgery. The patients records include anatomical studies which support a diagnosis of mixed cam-pincer type lesions at the right hip. Total hip arthroplasty would likely require revision and secondary procedures over the patients lifetime. In the article by Cheatham and colleagues, the authors noted that femoral acetabular impingement is a more commonly recognized intra-articular hip pathology and is often accompanied with a labral tear. Sansone and colleagues conducted a case series on 70 patients undergoing arthroscopic surgery for femoral acetabular impingement with preoperative radiological signs of mild-to-moderate osteoarthritis. The authors reported on findings at two-year follow-up using functional outcome measures. The authors reported that 82% of the 70 patients reported satisfaction with the outcome of the surgery. The diagnostic criteria included patient history, physical examination and radiological findings of either cam or pincer type changes or mixtures of both. The authors concluded that patients with mild-to-moderate osteoarthritis Tonnis grades 1 and 2 benefitted the most from arthroscopic treatment of femoral acetabular impingement. All told, the requested arthroscopic hip surgery is medically necessary for treatment of this patients mixed cam-pincer type femoral acetabular impingement syndrome with a tear of the acetabular labrum within the anterosupralateral quadrant of the right hip. Based on the foregoing discussion, the requested surgery is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.