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

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for knee arthroscopy with meniscectomy performed on 9/25/18. 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 this patient presented with progressive right knee pain with associated mechanical symptoms of swelling, catching, and locking. Her pain interfered with activities of daily living and affected her quality of life. Clinical examination findings documented positive McMurrays test consistent with imaging evidence of medial and lateral meniscus tears. There was radiographic evidence of moderate to severe right knee osteoarthritis. She failed to improve despite conservative treatment, including activity modification, medications, physical therapy, and physician directed rehabilitation. She underwent right knee arthroscopy with medial and lateral meniscectomies, synovectomy, and debridement with removal of crystals on 9/25/18. The medical evidence supports the services at issue in this clinical setting. Therefore, knee arthroscopy with meniscectomy performed on 9/25/18 was medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 53-year-old male enrollee has requested reimbursement for MRI of the lumbar spine without dye performed on 3/22/19. 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 this patient had a history of low back pain for greater than two years. Neurological examination had been normal for greater than two years, and there had been no weakness, absent reflex, history of tumor or infection, or trauma to serve as a red flag to mandate immediate imaging with MRI. The patient was prescribed chiropractic manipulation and massage therapy during his visits in 2017 and 2018. Unless there is a red flag indication, the current guidelines support a six-week course of conservative therapy, including physical therapy, and then re-evaluation prior to pursuing MRI for low back pain. In this case, the course of physical therapy prescribed by the patients chiropractor and planned follow-up afterward occurred after the MRI had been done, not beforehand as required by the national guidelines for MRI of the lumbar spine. Therefore, MRI of the lumbar spine without dye provided on 3/22/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 38-year-old female enrollee has requested authorization and coverage for Humira 40 mg weekly.  The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees ulcerative colitis. The physician reviewer found that there is data from prospective registry trials indicating that up to one-third of patients on Humira may require an increase in dose to weekly. Rather than abandon the entire class of anti-tumor necrosis factor drugs, modern algorithms suggest increasing Humira to weekly before switching to another class. Thus, there is support for weekly Humira in this patients case. In sum, Humira 40 mg weekly is likely to be superior over other available treatment options. Based upon the information set forth above, the requested medication dosage 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 1

A 59-year-old female enrollee has requested reimbursement for the computed tomography (CT) scan performed on 11/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees risk of coronary artery disease. The physician reviewer found that although there is ample data demonstrating how coronary calcium scoring can provide incremental risk stratification, to date there is a lack of data which assess the benefit of this technology in terms of interventional outcomes. Given that this patient is currently treated with a statin as well as antihypertensive therapy, it is unlikely that coronary calcium scoring would provide meaningful benefit or significant alteration in medical management. Therefore, the CT scan performed on 11/17/16 has not been established as 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 diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


The patient is a 59-year-old female who was diagnosed with malignant melanoma in February 2016. The records noted Breslow thickness of 1.28 mm, Clark level IV. Per the pathology report, the margins of excision were free of melanoma. The patient has requested reimbursement for gene testing performed on 5/12/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the DecisionDx-Melanoma testing performed in this case. The results of this testing were not likely to have changed treatment decisions. There is a lack of evidence from the literature that tailored follow-up according to the results of this testing has an impact on long-term outcomes. Therefore, the superior efficacy of gene testing performed on 5/12/16 has not been established. 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: Experimental
Decision: Upheld

Summary Reviewer 1


A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found the patient is a 40-year-old female who had a malignant melanoma excised from the skin of the mid lower back. A surgical pathology report noted a diagnosis of malignant melanoma, superficial spreading type with a Breslow thickness of 0.81 mm, Clark level II, area of possible regression, and no evidence of satellitosis. The tumor was noted to be mainly amelanotic. Decision Dx testing revealed Class 1A molecular signature associated with a low risk of recurrence within five years. The patient is requesting reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Insurer has denied this request as investigational.The testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with Decision Dx melanoma, the tumor was classified as Class 1 with a low risk of near-term (within five years) metastatic disease, such as 97% metastasis free rate. Although Decision Dx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, Decision Dx melanoma was not 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 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 19-year-old male enrollee has requested reimbursement for wilderness treatment program services provided from 10/23/18 through 1/16/19. 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 the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm due to a recent pattern of excessive substance use resulting in loss of self-control and harmful behaviors with no demonstrated ability to abstain from use. In terms of functional status, the records support a score of 3. The records documented a need for a leave of absence from school due to substance abuse, as well as recent gains in sobriety achieved in a structured setting. With regard to comorbidity, the records support a score of 3. The patient had significant comorbidity due to interaction between substance use and psychiatric disorders, as well as recent head injuries. 
In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to exposure to alcohol and drug use on his college campus. With regard to level of support of the recovery environment, the records support a score of 3. The patient was reluctant to seek support or help for his mental health issues and substance abuse while enrolled in college. In terms of treatment and recovery history, the records support a score of 1. There was no prior experience with treatment or recovery. With regard to engagement and recovery status, the records support a score of 3. The patients records documented limited ability to accept responsibility for recovery. Thus, the patient had a composite score of 20. In sum, medically monitored residence-based services were indicated in this setting. Therefore, wilderness treatment program services provided from 10/23/18 through 1/16/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 48-year-old female enrollee has requested reimbursement for the lab testing provided on 11/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees migraines, mild memory impairment, and prior syncope. The physician reviewer found that laboratory testing in patients with migraine headache, syncope, and cognitive impairment is not supported for hypercoagulable disorders in the absence of stroke or vascular disorder. The records do not reflect any vascular disorder or findings in support of stroke or ischemic brain event in this patient. Emmi and colleagues noted that laboratory evaluation is supported when there is vascular ischemic events. Antiphospholipid antibody syndrome should always be considered as a potential diagnosis especially for young patients presenting with a history of thrombotic events, in particular when they occur without any obvious external trigger or any inherited thrombophilic mutation, or for women with recurrent pregnancy losses or later fetal deaths. Migraine, syncope and cognitive disorders are not included as indications for this type of testing. Further, Reddy supports laboratory evaluation in setting of thrombotic events but not for diagnosis of migraine, syncope or cognitive disorder in absence of thrombotic event. Accordingly, the lab testing provided on 11/28/16 was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for gene testing for prostate cancer performed on 4/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the gene testing for prostate cancer performed on 4/21/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Polaris test is a cell cycle proliferation score based on 31 genes and adds prognostic value in predicting risk of recurrence in patients undergoing definitive treatment. The test is not used to determine whether or not to treat but how aggressive to treat. Although not supported by the National Comprehensive Cancer Network (NCCN) guidelines, Prolaris is supported by the medical literature as a standard of care on how best to stratify patients that require some kind of definitive therapy. Based on the medical literature cited above, the services at issue were 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 65-year-old female 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 investigational for the treatment of the enrollees medical condition. The physician reviewer found that Proton beam radiation therapy is a standard of care and medically appropriate in this clinical setting. This patient has received external beam radiotherapy to her left parotid region in the past. It is imperative to minimize the volume of normal tissue re-exposure in order to reduce the risk of treatment-related morbidity. The provider performed a proton/intensity modulated radiation therapy (IMRT) comparison plan which revealed that there was excessive cumulative exposure to the patients surrounding normal tissues with the IMRT plan, while the proton radiation plan was able to reduce this exposure to within known safe normal tissue tolerance limits. Proton beam radiation therapy is the most appropriate radiation modality in this setting. Therefore, proton beam radiation therapy is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 42-year-old female enrollee has requested reimbursement for supraorbital, occipital and suprascapular nerve blocks of the occipital nerve performed on 10/3/16 and 10/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic headache. 
 The physician reviewer found that the medical evidence do not support the use of occipital nerve blocks, supraorbital and suprascapular blocks for the treatment of migraine or other type headaches. The blocks are supported for diagnostic purposes but are not supported for therapeutic treatment. Peer reviewed medical literature have not shown long term benefit of occipital nerve blocks for treatment of migraine. In 2015, Dilli and colleagues noted that greater occipital nerve block does not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. In sum, the supraorbital, occipital, and suprascapular nerve blocks of the occipital nerve on 10/3/16 and 10/20/16 were not likely to have been more efficacious than the standard treatment options available for treating this patients medical condition. Based upon the information set forth above, the services at issue were 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 64-year-old female enrollee has requested reimbursement for knee injections provided on 6/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that this patient presented on 6/15/18 with recurrent right knee pain and limitations in functional mobility and activities of daily living. Clinical examination findings were consistent with reported radiographic evidence of right knee degenerative joint disease. Reasonable conservative treatment, including medications, activity modification, weight loss, and physical therapy have failed to provide adequate symptom relief. She was status post previous injections on 12/19/16 and 9/22/17 which had provided sustained pain relief and functional improvement for longer than six months. Evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, knee injections provided on 6/15/18 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 43-year-old male who was diagnosed at age 41 with adenocarcinoma of the prostate. The patient has requested authorization and coverage for positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging, skull based to mid-thigh. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that following radical prostatectomy, it is expected that PSA levels should become non-detectable.  When they remain elevated, it is an indication that there is still functioning prostatic tissue or metastatic disease. The National Comprehensive Cancer Network (NCCN) recommends following PSA levels, and when PSA levels increase on two successive assays, considering imaging, such as chest x-rays, bone scans, CT, magnetic resonance imaging (MRI), and PET scans. Prostate bed biopsy is also a consideration. One problem is the lack of accuracy of the various imaging modalities when the post-radical prostatectomy PSA levels are low, but rising. These patients generally will have a recurrence, but it will often be undetectable with conventional imaging modalities. Bone scans will be rarely positive in patients with PSA levels less than 10. Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases). CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease.  Microscopic or small lesions will be very difficult to detect. In order to effectively cover the areas detectable by PET scanning, one would have to perform CT or MRI scans of the head, neck, chest, abdomen, and pelvis. The value of PET scanning, especially when combined with CT scans, is that it depends on metabolic changes to detect abnormalities. Once recurrence is identified and localized, targeted therapy such as radiation can be utilized. There is sufficient support for the requested services in this clinical setting. Based on this patients rising PSA levels, and especially considering his young age, aggressive evaluation is warranted. Therefore, the requested PET with concurrently acquired CT for attenuation correction and anatomical localization imaging, skull based to mid-thigh is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 29-year-old female with Crohnas disease. The patient has requested authorization and coverage for Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that this patient has moderate to severe Crohnas disease based on age below 30 at diagnosis. Per American Gastroenterological Association guidelines for therapy of moderate to severe Crohnas disease, immunosuppressants, such as azathioprine, 6-mercaptopurine, and methotrexate, are not recommended as primary monotherapy. For patients with moderate-severe Crohnas disease, immunosuppressants may take up to 17 weeks to be effective, and aminosalicylates, corticosteroids, and antibiotics are not recommended as long-term primary therapy as they are unlikely to prevent complications. American College of Gastroenterology guidelines also do not recommend immunosuppressants or methotrexate as primary monotherapy for the induction of remission of Crohnas disease, stating, aAzathioprine and 6-mercaptopurine are not more effective than placebo to induce short-term symptomatic remission and should not be used in this manner.a The guidelines do recommend Stelara as a primary monotherapy for the treatment of Crohnas disease. A large randomized controlled trial by Sandborn and colleagues demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate-severe Crohnas disease. Another study by Kopylov and colleagues showed a 73% response in patients with anti-tumor necrosis factor-resistant Crohnas disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. Therefore, Stelara (ustekinumab IV solution 130 mg/26 ml (5 mg/ml) is medically necessary for the treatment of this patient.