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

Summary Reviewer 2

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). 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 limited high-quality data on the management of recurrent pregnancy loss. Currently, therapeutic recommendations are largely based upon clinical experience and data from observational studies. This patients provider seeks to treat her recurrent pregnancy loss thought to be of autoimmune nature with intravenous immune globulin (IVIG). The studies cited by the provider are observational and pre-date current systematic reviews. Systematic reviews have consistently found no beneficial effect of immunotherapy for treatment of recurrent pregnancy loss. Wong and colleagues performed a systematic review of 20 trials of high-quality. The authors noted that immunotherapy did not result in a statistically significant improvement in live births compared to untreated controls. Treatment with intravenous immune globulin was included in this study. In sum, immune globulin injection (Gamunex-C), 500 mg is not likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

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 various studies have found that fecal calprotectin correlates with endoscopic finding of inflammation and serum markers of inflammation in Crohns disease (Mao, et al; Kopylov, et al). Further studies have found that fecal calprotectin is useful to assess disease activity in Crohns disease (Walsham, et al). The test allows non-invasive assessment of Crohns disease. The American Gastroenterological Association (AGA) guidelines for the management of Crohns disease recommend fecal calprotectin to assess disease activity in patients with Crohns disease. For these reasons, the laboratory services (CPT code 83993) performed on 10/5/17 was likely to be more beneficial for evaluation of this patients Crohns disease 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 1

A 60-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a 31-gene assay of molecular pathology in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx Melanoma data compares to the ten-year Balch data. Most importantly, it is unknown if it can be used to make clinical therapeutic decisions. This would be particularly true in this patient with an excellent prognosis. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3  The parent of a 16-year-old female enrollee has requested reimbursement for intra-operative 
electromyography (EMG) monitoring and neuromuscular junction testing during spinal surgery 
including anterior cervical procedures on 2/14/22. The Health Insurer has denied this request 
indicating that the services at issue were investigational for the treatment of the enrollee.The 
physician reviewer found that while there may be limitations with respect to the degree of 
impairment  measured  during  intraoperative  monitoring,  particularly  with  less  invasive 
methodologies, the aggregate evidence  in current  medical literature uniformly supports this 
adjunctive approach to measuring spinal cord integrity and the potential for spinal cord injury. As 
operator skill and experience may vary widely during this type of surgery, and the potential for 
negative outcomes can be devastating in terms of postoperative morbidity, the service at issue was 
in keeping with best medical practice in the clinical setting of surgical repair of this patients 
scoliosis. Therefore, intra-operative EMG monitoring and neuromuscular junction testing during 
spinal surgery including anterior cervical procedures on 2/14/22 was likely to have been more 
beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 62-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Nanni and colleagues noted that evaluation of multiple myeloma bone disease at diagnosis should include both magnetic resonance imaging (MRI) of the spine and (18)F-FDG positron emission tomography/computed tomography (PET/CT).  Zamagni and colleagues noted that PET/CT may provide additional and valuable information for the assessment of myeloma bone disease in areas not covered by MRI.  Therefore, the requested PET scan is likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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  46-year-old  female  enrollee  has  requested  authorization  and  coverage  for  bone  marrow 
aspiration (38220). 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 tibial fracture and nonunion is a known complication of tibial tubercle 
osteotomy surgery. Achieving healing of established long bone nonunions is difficult, and standard 
treatment includes both internal fixation and grafting.  Grafting with the patients own bone has 
long been considered the most effective way of achieving healing. Konda and colleagues noted, 
Given the high union rate, autogenous iliac crest bone grafting for tibial nonunion remains the 
gold standard for this difficult condition. However, surgically removing bone from the iliac crest 
carries its own complications, and more recently multiple peer-reviewed scientific studies have 
compared bone marrow aspirate and concentration as a way of transplanting live bone cells to 
stimulate fracture nonunion healing without surgical removal of bone. Multiple studies in various 
clinical settings, including treatment of long bone nonunions, hindfoot fusions and spinal fusions, 
have found bone marrow aspirate to be equally effective to surgical harvest of bone with the 
advantage of less patient pain and risks of complications related to harvest of bone. In this case, 
the provider has recommended bone marrow aspirate as an alternative to harvest of bone graft for 
the treatment of the patients established tibial nonunion. Bone grafting for established nonunion 
is a component of standard treatment of tibial nonunion. Thus, the bone marrow aspirate is 
medically appropriate. The proposed bone marrow aspirate is not in addition to standard treatment, 
rather it is an alternative to more traditional surgical harvest of bone with the advantage of being 
more minimally invasive and carrying less risk of complications. Iliac bone marrow aspirate is 
likely to be more beneficial than treatment of the patients tibial nonunion without autogenous 
bone grafting. Therefore, the requested bone marrow aspiration (38220) is likely to be more 
beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 28-year-old male enrollee has requested reimbursement for residential rehabilitation level of care services provided from 8/4/16 through 8/19/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that this patients records did not include any psychiatric or medical admitting evaluations. In addition, the patient did not present with any significant post-acute withdrawal symptoms. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant RTC level of care. He was medically and psychiatrically stable. He was motivated, insightful, and appeared to be working the program. He reported having had a multitude of prior treatments, with the ability to maintain abstinence for a prolonged period of time. Relapse risk is inherent among this population but is not alone an adequate reason to keep a patient at a higher level of care in the absence of unstable psychiatric illness or the potential for harm to self or others. Given the recidivistic nature of his illness with multiple relapses and subsequent treatments, he had the groundwork of relapse prevention education. His difficulties with abuse and relapse were chronic in nature and did not require 24-hour monitoring at the RTC level of care in the absence of unstable medical or psychiatric conditions. He could have safely been treated in a less restrictive level of care. Thus, the RTC rehabilitation level of care services provided from 8/4/16 through 8/19/16 were not medically necessary for treatment of this patients polysubstance abuse. 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: Upheld

Summary Reviewer 3


A 26-year-old male enrollee has requested authorization and coverage for the LINX reflux management system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).  The physician reviewer found in this clinical setting, the requested procedure is likely to be more beneficial for treatment of this patients GERD than any available standard therapy. LINX is a minimally invasive anti-reflux procedure that has been approved by the Food and Drug Administration. In addition, medical studies indicate that LINX has been shown to be as effective and non-inferior to surgery.  A systematic review of more than 6,318 abstracts, 53 cohorts and 10 controlled studies has shown that it remains unclear which patient characteristics influence postoperative success following fundoplication for GERD. All told, LINX is at least equally efficacious as fundoplication and is less invasive (Ip et al). Further, the LINX procedure is potentially reversible, while surgery is not, and is less likely to have adverse effects. For all these reasons, LINX is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, 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 57-year-old female enrollee has requested reimbursement for tumor necrosis factor antagonist testing performed on 4/04/15.  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 submitted records fail to demonstrate the superior efficacy of the services at issue.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or adalimumab or the presence of infliximab or adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  While there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  Thus, tumor necrosis factor antagonist testing performed on 4/04/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 25-year-old enrollee has requested reimbursement for bilateral nipple/areola reconstruction associated with gender reassignment surgery performed on 10/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the medical necessity of the services at issue. The Health Insurer is incorrect in its understanding of the nature of the most common chest surgery for transmasculine patients. As noted by Schechter and Schechter, patients with small non-ptotic breasts can often be treated with periareolar incisions but most patients require double incision surgery with free nipple grafts, as sought by this patient. The authors noted generally, free nipple-areola grafts, as opposed to maintenance of the nipple-areola complex on the dermoglandular pedicle are the preferred techniques for nipple transposition. Olson-Kennedy and colleagues demonstrated that for transmasculine individuals, this surgical intervention positively affected both minors and young adults. In sum, bilateral nipple/areola reconstruction associated with gender reassignment surgery provided on 10/30/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 47-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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 patient is a 47-year-old female who presented to her primary care provider on 7/25/19 for establishment of care. The patient has requested reimbursement for vitamin D testing performed on 7/30/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders.   Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people or those who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the patient does not have any chronic medical conditions that would cause vitamin D deficiency. She did not have any signs or symptoms of vitamin D toxicity or severe deficiency. Therefore, vitamin D testing performed on 7/30/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 38-year-old male enrollee has requested authorization and coverage for neck surgery.  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has left C6 radiculopathy with matching motor and sensory symptoms and findings. Thus, there is disc herniation at C5-6. However, the use of Mobi-C remains controversial.  There is a lack of studies demonstrating the long term safety and effectiveness of this device. There are is a lack of controlled, prospective studies that have reported the long term safety and effectiveness of this device. According to Zechmeister and colleagues 
cervical total disc replacement (CTDR) is not recommended for routine use. The authors further state that Future research needs to address the relative effectiveness between CTDR and conservative treatment. All told, the requested neck surgery 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: Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for substance abuse partial hospitalization services provided from 8/16/14 through 9/01/14.  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 the submitted documentation supports the medical necessity of the services at issue.  This patients opioid use disorder and concomitant abuse of benzodiazepines further exacerbated the risk for an unfavorable outcome.  Her addiction dominated her daily routine and generated distress.  Additionally, her opioid use strained meaningful relationships and caused significant impairment across multiple domains of functionality.  In this patients case, the treatment provided was safe, appropriate and consistent with good practice.  The services were reasonably expected to improve her condition and prevent a more serious episode of illness.  Further, the duration of the disputed treatment was within community practice standards.  All told, substance abuse partial hospitalization services provided from 8/16/14 through 9/01/14 were medically necessary 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 35-year-old male enrollee has requested authorization and coverage for Actemra 400 mg/ 20 ml vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees anti-neutrophil cytoplasmic autoantibodies (ANCA) associated crescentic and immune complex glomerulonephritis. The physician reviewer found according to the Clinical Practice Guidelines for Glomerulonephritis, crescentic glomerulonephritis with ANCA is usually treated with a set of three pulsed doses of methylprednisolone, prednisone 60 gm/day followed by a taper; and cyclophosphamide for six months followed by azathioprine for 18 months. Plasmapheresis is added if there is alveolar hemorrhage and/or dialysis requirement. Recurrences are treated with rituximab. Rituximab may also be a substitute for cyclophosphamide for initial therapy. Recurrences are retreated with the same agents. However, there is a lack of medical literature supporting tocilizumab for the treatment of ANCA. All told, the request for Actemra is not likely to be more beneficial for treatment of the patients medical condition than other modalities. Based upon the information set forth above, the requested medication is 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.