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

Summary Reviewer  
The patient is a 28-year-old female who presented to her provider on 11/4/22. The patient has 
requested authorization and coverage for omalizumab (Xolair) 150 mg. The Health Insurer has 
denied this request and reported that the requested medication is not medically necessary for the 
treatment of this patient. This denial is the subject of this appeal and determination. The physician 
reviewer found that the submitted documentation supports the medical necessity of the requested 
medication. Xolair is a biologic therapy that targets specific inflammatory pathways involved in 
the  pathogenesis  of  asthma,  particularly  in  patients  with  an  endotype  driven  by  type  2 
inflammation. This targeted therapy has been shown to reduce asthma exacerbations, improve lung 
function, reduce oral corticosteroid use, and improve quality of life in appropriately selected 
patients. The U.S. Food and Drug Administration (FDA) approves the use of omalizumab for 
patients with moderate-to-severe asthma over age six, with a positive skin test or in vitro reactivity 
to at least one perennial allergen, and with symptoms that are inadequately controlled with inhaled 
corticosteroids. In this case, the records documented a serum Ig E level of 384.1 IU/mL on 
10/26/22, along with positive serum allergen specific IgE levels for dust mite, mold, and pollens. 
The patient has continued to experience persistent asthma symptoms such as dyspnea despite 
combination therapy of inhaled corticosteroids and a long-acting bronchodilator. Given that 
current  medical  literature  supports  the  use  of  the  requested  medication  for  patients  with 
uncontrolled  allergic  asthma  symptoms  in  this  clinical  setting,  the  requested  medication  is 
medically indicated. Therefore, omalizumab (Xolair) 150 mg is medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 60-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) scan of the shoulder. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the evaluation of the enrollees shoulder pain. The physician reviewer found that the submitted documentation does not support the medical necessity of the requested services in this clinical setting. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations. The ACR recommends obtaining plain x-rays as a first line evaluation of shoulder pain. The next study recommended is MRI. However, in this patients case, MRI is not medically indicated at this time. It is unclear how recent the trauma occurred and it would be expected that an MRI might show changes of wear and tear. Similarly, in a study by Schwartzberg and colleagues, they found a high rate of superior glenoid labral tear diagnoses based on MRI in a cohort of middle-aged, asymptomatic people. The study indicated that rotator cuff tears or labral tears are common, especially in the elderly, and that it is important to remember that their presence does not always impute pain or clinically significant loss of function.  This study reaffirms that magnetic resonance findings are not necessarily an explanation for the patients symptoms. In this patients case, he has not undergone a trial of intensive conservative management.  Three months of conservative treatment with persistence of symptoms is not unreasonable. All told, MRI of the shoulder is not medically necessary for the evaluation of this patient. Therefore, for the reasons stated above, 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: Upheld

Summary Reviewer 2

A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. 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 Dysautonomia is an umbrella term referring to any disorder associated with dysfunction of the autonomic nervous system. There are many different mechanisms by which dysautonomia may arise, but there has been increasing evidence and awareness that it may be immune-mediated in some patients. Autoimmune autonomic dysfunction may be peripheral due to an immune-mediated small fiber polyneuropathy (SFPN) and may manifest clinically as postural tachycardia syndrome, orthostatic intolerance, orthostatic hypotension, inappropriate sinus tachycardia, gastrointestinal dysmotility, complex regional pain syndrome, and/or neurogenic bladder. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy. Oaklander and Klein reported on the efficacy of immune modulatory therapy in children with SFPN. Fifteen patients were given a trial of immune modulatory therapy with IVIG and/or steroids, and 12 patients (80%) demonstrated improvement. A retrospective analysis by Schofield and Chemali studied the efficacy and safety of IVIG in patients with disabling, refractory autoimmune dysautonomias, including patients with postural tachycardia syndrome and gastrointestinal dysmotility. There were 38 patients, and 83.5% improved on IVIG as defined by at least 20% improvement in the composite autonomic symptom scale 31 and/or functional ability score. The authors concluded, aThere is increasing evidence that IVIG is safe and effective in a subset of patients with autonomic disorders and evidence for autoimmunity. A four-month IVIG trial should be considered in severely affected patients who are refractory to lifestyle and pharmacological therapies.a In this case, the patient has an underlying autonomic nervous system dysfunction on multiple medications. Based on the studies noted above, patients with dysautonomia may improve clinically with intravenous immunoglobulin treatment. Therefore, Octagam infusions are likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 11/07/18 through 11/15/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees 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 the necessary level of care for children. With regards to risk of harm, the records support a score of 2. The documentation indicates that the patient was not actively suicidal but did report she was passively suicidal on one occasion. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function due to mental illness and relational issues but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient did not have a history of past medical issues or substance use. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a good relationship with her family. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents are involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. The patient had a good response to a short period in the residential treatment center with minimal continued signs or symptoms of anxiety and depression. She was participating in therapy while on the unit and was not displaying serious or disruptive symptoms. In terms of acceptance and engagement of the patient, the records support a score of 2. The records documented that the patient participated in therapy. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential treatment provided from 11/07/18 through 11/15/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 39-year-old male with a history of remote anterior cervical discectomy at C5-6 followed by adjacent segment disease and revision anterior cervical discectomy and fusion. The patient has requested authorization and coverage for spinal surgery. The Health Insurer denied the request indicating that the requested services are not medically necessary. The physician reviewer found that the patient has recurrent neck pain associated with radicular pain and evidence of left C7 radiculopathy. The MRI findings corroborate the clinical findings. He has failed conservative treatments. As such, he is a candidate for surgery. The provideras recommendation with regard to the surgical procedure is appropriate and is supported by the medical literature. No adjacent segment disease occurs below C7. As such, a total disc replacement is not necessary. The selected procedure is supported by the clinical and MRI findings and is likely to be beneficial based upon a review of the literature. The requested services are medically indicated for management of the adjacent segment disease and associated C7 radiculopathy of the patient. Therefore, spinal surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found the minimally invasive SI joint fusion has not been demonstrated to result in superior health outcomes for the treatment of back pain when compared to standard available treatment options. Further, this patients medical records do not show any evidence of SI joint instability, fracture, or tumor, thus the criteria for SI joint fusion are not met. This patient has chronic back pain after previous lumbar fusion surgery. The pain is likely degenerative in cause. For these reasons, the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 33-year-old female who has a history of a motor vehicle accident in April 2018. The patient has requested reimbursement for physical therapy provided from 4/30/20 through 6/26/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the management of chronic benign musculoskeletal pains affecting body regions such as the neck, shoulders and back can include pharmacological agents, rehabilitation, psychological treatment, complementary/alternative medicine and invasive approaches. The aim of rehabilitation is to reduce pain, reduce impairment/disability, and improve quality of life. Formal rehabilitative interventions are rendered, in conjunction with education, towards a goal of self-management, independent exercise and remaining active. Exercise and physical activity have low risk for adverse effects and are generally encouraged in the setting of these types of chronic pains. The benefit of prolonged exercise and formal modalities in a formal therapy setting, however, is not established in the medical literature. There is no proven marginal benefit of prolonged formal therapy in the chronic pain clinical setting over independently pursued exercises and independently rendered interventions, such as self-massage (e.g., using foam rollers, massage balls, etc.) and topical treatments, such as ice or heat. In this case, the patient experienced some major life stressors in early 2020 and reported exacerbations in her chronic symptomatology. She did not, however, have any documented impairments that would have precluded her from performing an appropriate independent exercise program, including stretching and strengthening, as well as independent soft-tissue and palliative interventions, e.g., self-massage using foam rollers or massage balls, and topical treatments such as ice or heat, during the time period under review. Although the patient had been making some subjective and nominal progress with therapy, there would have been no expectation of a marginally significant difference in clinical course or outcomes with the formal therapy in question over an appropriate independent program and the passage of time. She would have been expected to have had some persistent and fluctuating symptomatology, just as she did despite receiving the therapy services during this time period. Therefore, physical therapy provided from 4/30/20 through 6/26/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 60-year-old female who has a history of pain and pressure around her left ear. Per the notes provided, she has seen otolaryngology specialists, and her symptoms were felt to be secondary to temporomandibular joint disorder. The physician reviewer found that the current well-accepted test to identify the presence or absence of temporomandibular joint disorder or one of its subcategories is a comprehensive evaluation of the patientas history and clinical examination and, when indicated, select temporomandibular joint imaging. The panoramic radiograph is the initial study of choice for evaluation of the temporomandibular joint. CT scan is indicated when bony pathology is suspected and can better delineate bony anatomy and demonstrate any degenerative changes. Given the patientas clinical findings, which included crepitus of her temporomandibular joint, a CT scan was appropriate to evaluate her temporomandibular joint for any degenerative changes. Therefore, CT scan performed on 10/28/20 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 54-year-old female who presented to her provider on 3/1/22. The documentation 
noted a history of excision of back fat in 2018. The patient has requested authorization and 
coverage for suction lipectomy head/neck (15876). The Health Insurer has denied this request and 
reported that the requested service is not medically necessary for the treatment of this patient and 
is not reconstructive in nature. This denial is the subject of this appeal and determination. The 
physician reviewer found that at issue in this case is whether suction lipectomy head/neck (15876) is 
medically necessary for treatment of the patients medical condition. In addition, does the patients 
condition constitute an abnormal structure of the body? If so, is the abnormal structure of the body 
caused by any of the following: congenital abnormalities; developmental abnormalities; trauma; 
infection; tumors or disease? If so, is the requested surgery performed to do either of the following: 
improve function or create a normal appearance to the extent possible? If so, does the surgery 
provide more than a minimal improvement in the appearance of the patient? In this case, the patient 
is five feet and five inches tall and weighs 138 pounds. She is not obese, and a physical examination 
did not reveal any pain, trauma, masses, infections, congenital defects, wounds or any limitations 
in terms of range of motion.  In this case, the requested service is not medically indicated. 
Therefore, suction lipectomy head/neck (15876) is not medically necessary for the treatment of 
this patient. In this case, the patient is not obese, and a physical examination did not reveal any 
pain, trauma, masses, infections, congenital defects, wounds and or any limitations in terms of 
range of motion. The patient does not have tumor defects of the breast, deformities caused by 
infections and/or trauma, or lipedema causing pain. The patients condition does not constitute an 
abnormal structure to her body. Surgery would not be improving any function. While a surgery 
may  well  improve  the  appearance  of  the  involved  area,  this  would  only  be  a  cosmetic 
improvement. Thus, the requested procedure is not being performed to improve function or create 
a more than minimal improvement in the patients appearance. Therefore, suction lipectomy 
head/neck (15876) is not reconstructive in nature.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 7/01/20. 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 there is a lack of support for the services at issue in this setting. Prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed as being able to classify cutaneous melanoma into separate categories used on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Various (mostly retrospective) studies of prognostic gene expression profiling (GEP) testing suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies (as have been performed in breast cancer) are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 7/01/20 was not likely to have been more beneficial than other available standard therapy
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. 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 bone turnover marker assays measure collagen breakdown products released from osteoclasts and osteoblasts during the process of bone resorption and formation. Measurement of bone turnover markers is complicated by large random within-patient variability, biologic variability (age, gender, body mass index, circadian, and menstrual variation), and poor standardization of most assays. Uncertainties over its clinical use can be in part resolved by adopting international reference standards, which do not exist at this time. Guideline committees typically recommend against routine use of bone turnover markers, due to the limitations of measuring and interpreting bone turnover markers in individual patients. There is a lack of prospective trials to define the most optimal approach for incorporating bone turnover markers into the management of patients with osteoporosis. In sum, collagen crosslinking test (CPT 82523) performed on 9/07/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
The parent of a 16-year-old male insured has requested reimbursement for a laboratory test 
performed on 2/10/23. The Health Insurer has denied this request indicating that the services at 
issue were considered investigational for the evaluation of the insureds Chrons disease. 
The physician reviewer found that Therapeutic drug level monitoring (TDM) has become an 
essential procedure in the management of inflammatory bowel disease. Measuring the drug level 
and the presence of antibodies can help the treating physician differentiate between primary 
treatment failures versus insufficient dosing. It can also allow dosing titration and adjustments. 
The clinical practice guidelines adopted by the American College of Gastroenterology (ACG) 
support the use of therapeutic drug monitoring in the management of patients with inflammatory 
bowel disease (Vande Casteele, et al.). According to Singh and Dubinsky, Therapeutic drug 
monitoring allows for optimized, individualized dosing and improved care for inflammatory bowel 
disease patients of all ages. Finally, Fernandes and colleagues published a prospective study 
showing that proactive TDM is associated with fewer surgeries and higher rates of mucosal healing 
than conventional non-TDM-based management. Overall, TDM is well-supported by the medical 
literature and was performed appropriately in this patients case. Therefore, the laboratory test 
performed on 2/10/23 was likely to have been more beneficial for the evaluation of the patients 
condition than any available standard therapy.