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

Summary Reviewer 

A 59-year-old female enrollee has requested authorization and coverage for Saxenda Pen injector. 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 according to the guidelines from the Endocrine Society, diet, exercise, and behavioral modification should be included in all obesity management approaches for patients with body mass index greater than or equal to 25 kg/m2. For patients with a body mass index greater than or equal to 27 kg/m2 with comorbidity or a body mass index over 30 kg/m2, pharmacotherapy may be used as an adjunct to behavioral modification. Drugs may amplify adherence to behavior change and may improve physical functioning, such that increased physical activity is easier in those who cannot exercise initially. Patients who have a history of being unable to successfully lose and maintain weight and who meet label indications are candidates for weight loss medications. Saxenda (liraglutide) is a glucagon-like peptide-1 receptor agonist that has been successfully used in the treatment of type 2 diabetes for several years. Weight loss has been well-described as an additional benefit with liraglutide therapy, which prompted the manufacturer to evaluate and develop a higher dose formulation specifically for the treatment of obesity. Liraglutide 3 mg/day has been approved by the U.S. Food and Drug Administration for this indication. In this patients case, the records document a body mass index of 30.07 kg/m2. The current medical evidence supports the requested medication in this clinical setting. Therefore, Saxenda pen injector is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 35-year-old male enrollee has requested authorization and coverage for HP Acthar Gel 80 units. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Acthar gel has been approved by the U.S. Food and Drug Administration for multiple sclerosis relapses. In this case, the patient is unable to take traditional corticosteroids due to prior side effects. He has benefitted from Acthar gel. The medical evidence supports the requested medication in this clinical setting. Therefore, HP Acthar gel 80 unit/ml vial is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 51-year-old female with chronic left knee pain. The patient has requested authorization and coverage for knee arthroscopy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this patient has evidence of degenerative changes in the left knee along with meniscocapsular separation, meniscal cyst, and tearing of both menisci. Meniscocapsular separation is a lesion of the attachment of the peripheral section of the meniscus to the capsule and is less common than other meniscus injuries. Per Tiftikci and Serbest, a repair made with the all-inside method is successful clinically and functionally. In addition, it is recommended that the repair is made from the tibial surface, which does not change the anatomic position of the meniscus. A partial medial meniscectomy with removal of the unstable portions of the meniscus is recommended.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old male enrollee has requested authorization and coverage for left total knee replacement. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees knee pain. The physician reviewer found the records document that this patient has clinical and radiographic evidence of osteoarthritis of the left knee with a history of failed conservative treatment for over three years. The surgical criteria include pain, functional alteration, objective findings of deformity, loss of motion, radiological findings of osteoarthritis involving at least two compartments, and failure of conservative treatment. All of these indications have been well documented in this case. As such, the requested left total knee arthroplasty is medically necessary for treatment of this patients medical condition. 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 66-year-old male enrollee has requested authorization and coverage for Dupixent 300 mg/2 mL, quantity of four every 30 days. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees asthma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Dupixent is U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe eosinophilic asthma and atopic dermatitis. The patient does not have a diagnosis of atopic dermatitis. Although the records noted severe asthma eosinophilic phenotype, the documentation does not include a recent complete blood count showing peripheral blood eosinophils greater than 150 cells/uL in the last 12 months. The most recent documentation does not support that he has a diagnosis of oral corticosteroid-dependent asthma with persistent airflow obstruction. On 6/05/18, he was noted to have improved and even borderline obstruction in the pre-bronchodilator pulmonary function tests. The plan was to continue the current medications which included Singulair, Zyflo and Symbicort. The records do not support the requested medication in this clinical setting. As of 6/05/18, the patient had borderline obstruction and did not have oral corticosteroid-dependent asthma. Furthermore, there is no documentation in the last year of a complete blood count with significant eosinophilia. Thus, Dupixent 300 mg/2 mL, quantity of four every 30 days is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 55-year-old male enrollee has requested reimbursement for FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18. 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 the patient is reported to have had abnormal liver enzyme tests. The use of FibroTest has support in current medical literature for the evaluation of and for liver disease. The alternative, liver biopsy, is invasive, with risks including bleeding, bowel perforation, and bile duct injury. It is subject to interoperator variability and sampling error. Therefore, both initial and then if needed, long-term and repeated clinical monitoring, can more safely and effectively be done with serum markers such as FibroTest rather than repeated biopsies. Over the long-term, chronic liver disease can evolve into cirrhosis, which requires specific therapy and monitoring for complications. Therefore, identification of cirrhosis with a test such as FibroTest is important to prevent complications of unidentified cirrhosis or liver disease. For these reasons, FibroTest-ActiTest/HCV-Fibrosure test performed on 8/07/18 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 57-year-old male 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 severe, persistent asthma. The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. There are three bronchoscopic procedures. The first treats the right lower lobe, the second the left lower lobe and the third bronchoscopic procedure is for both upper lobes. Thomson and colleagues reported on the safety of the procedure but noted that there was no difference in forced expiratory volume in one second (FEV-1), emergency department visits, or hospital admissions between the bronchial thermoplasty group and the control group. This patients provider states that the patient has a progressive decrease in the quality of life. However, there is no documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. Thus, the requested bronchial thermoplasty 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 procedure 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 29-year-old female with a diagnosis of juvenile onset hypophosphatasia (HPP). The patient has requested authorization and coverage for Strensiq 80 mg/0.8 ml vial. 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 the clinical, genetics and laboratory findings of this patient are supportive of the diagnosis of HPP. Since Strensiq is the only U.S. Food and Drug Administration (FDA) approved medication that replaces deficient alkaline phosphatase and allows the patient to improve bone mineralization, which results in lower risk for further fractures, pain in the bones, muscles and chronic pain, the patient should benefit from a trial of this medication. In an open-label prospective study which included patients with perinatal-, infantile-, or juvenile-onset hypophosphatasia, enzyme replacement therapy (Strensiq) was associated with improved overall survival, ventilator-free survival, growth, and bone mineralization. A recent study that included adults showed that therapy with Strensiq was safe and provided benefit to patients, with improvements in gross motor function, muscle strength, and patient-reported functional disability over five years of treatment. Therefore, Strensiq 80 mg/0.8 ml vial is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 55-year-old female enrollee has requested reimbursement for inpatient hospital services provided from 3/01/18 through 3/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who reported chest tightness and dyspnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient presented with unforeseen symptoms possibly due to coronary ischemia associated with an abnormal electrocardiogram and normal initial troponin value. In this circumstance, a period of overnight observation without hospital admission is reasonable and appropriate to confirm no evidence of myocardial infarction with serial troponins prior to discharge. Since the patient was clinically stable after initial evaluation, with an anticipated length of stay of less than 48 hours or less than two midnights, hospital admission was not medically necessary. Based on the records, an observational level of stay would have been safe and effective. Thus, inpatient hospital services provided from 3/01/18 through 3/02/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 62-year-old female with a history of right foot pain and metatarsalgia of the right foot. 
The records available for review indicate that the patient had been experiencing pain in her foot and 
cramping of her toes for several years. The physician reviewer found that at issue is whether the 
osteotomy (CPT 28308) performed on 1/20/22 was medically necessary for the treatment of this 
patient.The current medical literature recommends an osteotomy with double screw fixation combined 
with plantar plate repair for the treatment of patients with a plantar plate tear and associated second 
MPJ metatarsalgia (Klein and Weil). The records available for review indicate that this patient presented 
with right foot pain for several years. The patient tried and failed conservative treatment measures such 
as local cortisone injections and off-loading arch supports. An ultrasound revealed a significant 
intermetatarsal neuroma and a plantar plate tear at the second MPJ. The current medical literature 
supports the use of an osteotomy to treat this patients foot pain after the failure of conservative 
measures. All told, the osteotomy (CPT 28308) performed on 1/20/22 was medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 57-year-old female who presented to urgent care on 7/12/18 for evaluation of left medial knee pain and swelling. Radiographs were obtained, reportedly demonstrating mild osteoarthritis, although no formal interpretation is available. The patient had a follow-up office visit on 7/31/18. On this date, the provider recommended physical therapy and the use of a knee brace. On 9/20/18, the patient reported mild improvement in symptoms after utilizing a knee brace, with little benefit from physical therapy. The patient has requested coverage for magnetic resonance imaging (MRI) of the left knee. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the evaluation of this patient. The submitted documentation fails to demonstrate the medical necessity of the requested services. The best initial imaging examination for the evaluation of chronic knee pain in an adult is radiographs. In the setting of osteoarthritis diagnosed by initial radiographs, MRI may be indicated in follow-up if the patients symptoms are not explained by the radiographic findings. According to the American College of Radiology appropriateness criteria for the evaluation of chronic knee pain in an adult with initial radiographs demonstrating degenerative changes, MRI may be appropriate as the next imaging examination. In this patients case, radiographs were reportedly obtained at an urgent care visit, although there was no formal radiological interpretation. Interpretation, presumably by the urgent care provider, reported mild osteoarthritis. In this patients case, a formal interpretation of the patients radiographs is necessary. The preliminary report issued by an urgent care physician may differ from an official report from a radiologist, possibly changing management. Thus, the requested MRI of the left knee 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees prostate cancer. The physician reviewer found that currently, there is insufficient clinical data to discern whether treatment with proton beam radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton beam radiation therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton beam radiation therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. The National Comprehensive Cancer Network guidelines indicate that no clear benefit of proton beam radiation therapy has been demonstrated over standard treatment with photons and IMRT technique. Therefore, the requested proton beam radiation therapy is not medically necessary for the treatment of this patient. Therefore, the requested services are 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 27-year-old transgender female who is seeking facial feminization surgery. The Health Insurer has denied authorization and coverage for transfeminine facial contouring. Per the Health Insurer, the requested services are not medically necessary for the treatment of the patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The purpose of medically necessary facial feminization surgery is to relieve gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a World Professional Association for Transgender Health (WPATH) stated, aNon-genital surgical proceduresanotably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitals.a The authors noted, aThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a Therefore, the requested transfeminine facial contouring is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 21-year-old female enrollee has requested authorization and coverage for placement of a cardiovascular defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee who has a family history of early repolarization syndrome (ERS) and an episode of syncope. The physician reviewer found The patient is a 21-year-old female who presented to her provider for syncope and ventricular tachycardia. Genetic testing has shown homozygous for genetic abnormality. Family history is positive for syncope due to cardiac arrhythmia and other family members also have implanted defibrillators. The patients diagnosis is early repolarization syndrome (ERS). Implantable cardiac defibrillator (ICD) was recommended by the treating provider. The Health Insurer denied the requested device as investigational/experimental for treatment of this patient. The diagnosis of ERS is an uncommon diagnosis with some uncertainty in the recommended treatment. However, this patient has been symptomatic with syncope and has the documented genetic abnormality. The most recent guidelines from American College of Cardiology and the European Society of Cardiology do not directly make treatment recommendations for this diagnosis. However, ICD is recommended for individuals with long QT syndrome and cardiac syncope, and this condition of ERS is very similar. Majida and colleagues noted that electrophysiological studies (EP studies) do not help differentiate individuals who are at higher risk of sudden death within this diagnosis group, so further EP study would not be helpful. With the documented genetic abnormality, the family history and the symptoms, the requested cardiovascular defibrillator is likely to be more efficacious than the standard treatment available for the treatment of this patient. Therefore, for the reasons stated above, the cardiovascular defibrillator 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 12-year-old male enrollee has requested authorization and coverage for Omnitrope growth hormone therapy. 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 the submitted documentation fails to demonstrate the medical necessity of the requested medication. The current medical evidence supports growth hormone therapy for children born small for gestational age, which is defined as birth weight or length two or more standard deviations below the mean for gestational age, who fail to manifest catch-up growth by two years of age, defined as height two or more standard deviations below the mean for age and sex. In this patients case, his height is close to the 50th percentile, and he has demonstrated catch-up growth. The growth velocity of 7.3 cm per year is normal. His predicted adult height is 59, which is the 50th percentile for a male in the United States. The predicted adult height is within two standard deviations of the mid-parental height of 72.1 inches. This patient does not meet the criteria for growth hormone treatment. Therefore, Omnitrope is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 43-year-old female with major depressive disorder. Per the records, she sustained hypoxic brain damage after an overdose on medications.  She has tried multiple medications for the treatment of her major depressive disorder. The records noted prior treatment with electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). The clinical notes document a history of abuse, insomnia and chronic pain. The patient has requested authorization and coverage for CPT 64568 (implantation of vagus nerve neurostimulator electrode). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The current medical evidence does not support the requested services in this patients case. On 1/29/18, the progress notes indicated that the patient was experiencing paranoia. These progress notes indicate that the patient was diagnosed with major depressive disorder with psychosis. There is a lack of support for the requested services for patients with psychosis. It is not clear whether the patient received evidence-based forms of psychotherapy for her major depressive disorder, which are the standard of care. The literature has limited support for the use of vagus nerve stimulation in unipolar depression. Thus, CPT 64568 (implantation of vagus nerve neurostimulator electrode) is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.