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

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for the Life Vest provided on 1/20/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees paroxysmal atrial flutter and atrial fibrillation with rapid ventricular response.   The physician reviewer found that an increase in the risk of sudden cardiac death, and a potential benefit from implantable cardioverter defibrillator (ICD) implantation, has long been recognized in patients with LV dysfunction related to underlying ischemic heart disease. An increase in sudden cardiac death risk and potential benefit from an ICD has also been demonstrated in patients with a non-ischemic cardiomyopathy (Chung, et al; Epstein, et al). The Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial compared ICD implantation with standard medical therapy to standard medical therapy alone for primary prevention of sudden cardiac death in patients with a non-ischemic cardiomyopathy, non-sustained ventricular tachycardia, and LV ejection fraction of 35% of less. The authors reported findings toward mortality benefit in patients who received an ICD, regardless of duration since diagnosis. This patient was found to have a LV ejection fraction of less than 35%. Thus, the use of the Life Vest provided on 1/20/14 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was 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 

A 64-year-old male enrollee has requested reimbursement for inpatient stay performed on 1/13/18. 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 after a fall from a ladder. He was diagnosed with bilateral radial nondisplaced fractures that did not require surgical treatment. He was treated conservatively with oral pain medications and splinting and discharged home the same day with plans for outpatient follow-up. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. His pain was well-controlled, and he did not have exacerbations of chronic medical problems. Therefore, the inpatient stay provided on 1/13/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 33-year-old female with a history of asthma, allergic rhinitis, aspirin allergy, and recurrent nasal polyps despite treatment with multiple nasal sprays. The patient has requested authorization and coverage for Dupixent. The physician reviewer found that Dupixent is a U.S. Food and Drug Administration (FDA) approved medication for adults with chronic rhinosinusitis with nasal polyposis, and the only approved therapy shown to shrink nasal polyp size and also improve the signs and symptoms of the associated chronic rhinosinusitis. This patient has persistent nasal polyposis after nasal surgeries two years ago, and she has had recurrent rhinosinusitis despite treatment with intranasal corticosteroids such as Flonase, Nasonex and XHance. The likely culprit of the recurrence of polyps is related to her aspirin allergy, as a condition called Samteras triad. It is a chronic condition called aspirin-exacerbated respiratory disease (AERD). The nasal polyps tent to recur despite standard treatment, such as the ones the patient has tried. The current medical evidence supports the requested medication in this clinical setting. Therefore, Dupixent is medically necessary.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that While there is some support in the medical literature for the requested procedure, there is a lack of independent data establishing the superior efficacy of this treatment in this clinical setting. A review of the literature indicates that hypoglossal nerve stimulation for treatment of OSA may show beneficial outcomes with minimal adverse effect. However, there are a lack of studies that directly compare outcomes of hypoglossal nerve stimulation to current standard therapies. As such, the implantation with hypoglossal nerve stimulator is not likely to be more beneficial than standard available therapy for treatment of this patient. Therefore, for the reasons stated 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 29-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 2/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that this patient demonstrated clinical response at the time of Anser IFX testing.  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 the presence of infliximab 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 IFX 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.  In sum, Anser IFX testing performed on 2/25/16 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for Anser ADA diagnostic testing performed on 2/18/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that based upon the medical records provided, the Anser ADA assay on 2/18/15 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient was symptomatic with diarrhea and Anser ADA assay was performed to rule out antibodies to Humira, and ensure therapeutic levels of the drug in an attempt to optimize therapy. Therapeutic drug monitoring (TDM) is the clinical practice of measuring drug concentrations or metabolites to attain a targeted concentration in a patient's bloodstream, thereby optimizing individual dosage regimens. Maximizing the efficacy of therapies for inflammatory bowel disease (IBD), while minimizing their toxicity remains the principal objective in developing management strategies for IBD patients. Recognition of the factors influencing therapeutic response allows providers to individualize dosing regimens to meet this objective. In order to optimize IBD therapy, it is critical that prescribers understand that standard dosing is insufficient for most patients, given the interindividual variability relating to response and tolerability. Moreover, the Anser ADA diagnostic test is considered safe and effective in optimizing therapy in patients with Crohns disease that are being treated with anti-tumor necrosis factor (TNF) agents such as Humira. The study by Li and colleagues noted a significant correlation between serum ADA levels and remission in patients with Crohns disease. Therefore, incorporation of Anser ADA diagnostic testing into clinical practice may allow providers to optimize treatment by maintaining effective drug concentrations over time. For the reasons provided, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than other modalities. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx test has shown some impressive accuracy in thin melanomas like this patients tumor. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The test has not been demonstrated to provide a beneficial effect on health outcomes. Overall, there is not enough published data to support its routine use. Since this test has not been demonstrated to provide a greater benefit beyond that anticipated with established tests, the DecisionDx-Melanoma assay provided on 2/14/17 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 2

A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found the request for a LINQ device is likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. The patient has been extensively evaluated with two Zio Patch event monitoring periods in 2016 and 2017, neither of these studies demonstrated an etiology for recurrent syncope. In addition the patient has a structurally normal heart as well as a negative electrophysiologic study which failed to demonstrate inducible arrhythmias or periods of high grade atrioventicular block. In light of these facts other than an implanted loop recorder there is no other diagnostic modality that would likely be more helpful. As such, request for a heart monitor (implantable ambulatory event monitor) is 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 device 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: Overturned

Summary Reviewer 1

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that as noted in the current medical literature, transanal hemorrhoidal dearterialization has been shown to have equivalent or superior outcomes when compared to standard available procedures. Ratto and colleagues concluded that transanal hemorrhoidal dearterialization appears to be a very effective minimally invasive option to treat hemorrhoids and can be performed in a day-surgery setting. Similar findings were reported by Sohn and colleagues. The records indicate this patients symptoms did not adequately respond to rubber band ligation or conservative measures. Given these findings, the Doppler guided transanal hemorrhoidal dearterialization provided on 11/20/17 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 61-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 the current medical evidence supports the requested services in this clinical setting.  Damle and colleagues noted that 18-F-fluoride positron emission tomography/computed tomography (PET/CT) is the most reliable method to rule out bone metastases in cases where there is a high index of suspicion.  The authors noted that PET/CT has the potential to replace the (99m) Tc-MDP bone scan for the detection of bone metastases.  In sum, the requested PET scan is likely to be of greater benefit than other modalities for 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 2


A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Plan has denied this request indicating that the requested procedure is considered investigational for the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found the appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery (Jobe, et al). In this case, the patient has undergone much of this pre-operative assessment but clinically significant reflux has not been demonstrated. In addition, the value of the LINX device in this clinical setting is uncertain. The patients pH recording demonstrated normal DeMeester scores (off acid blocker therapy) and her video esophagram did not show active reflux. Further, her infrequent reflux events proved poorly correlative with chest symptoms, thus, her ongoing symptoms cannot be considered medically refractory to acid blocker drugs. Also, implantation of the LINX device must be approached with caution given the patients documented complaint of dysphagia and demonstrated hang-up of a barium pill on esophagram. All told, the request for LINX procedure 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: Upheld

Summary Reviewer  
The patient is a 60-year-old male. The patient has requested reimbursement for magnetic 
resonance (e.g., proton) imaging (MRI), spinal canal and contents, cervical; without contrast 
material on 8/15/22. The physician reviewer found that at issue is whether the MRI (e.g., proton), 
spinal  canal  and  contents,  cervical;  without  contrast  material  on  8/15/22,  was  medically 
necessary for the evaluation of this patient. The submitted documentation does not support the 
medical necessity of the service at issue. The treatment for chronic musculoskeletal pain, 
including benign neck pain with or without radicular symptoms, includes patient education, self-
care, independent exercise, remaining active, basic topical thermal modalities for palliation, and 
common analgesics, if warranted, for palliation. Childress and colleagues note that in the initial 
evaluation and management of neck pain, diagnostic tools such as imaging have variable utility. 
Early MRI imaging is not known to improve outcomes in this clinical setting and may lead to an 
overemphasis in invasive procedures and surgery that are ultimately not clinically beneficial. In 
this case, the records did not document red flags in the patients history or examination such 
as symptoms or signs suspicious for infection, abscess, bleeding, or tumor, that would indicate 
advanced imaging of the cervical spine without an appropriate trial of conservative therapy. 
Notes dated 8/15/22 reported a normal neurological examination, and an examination of the 
cervical  spine  showed  normal  range  of  motion  with  tenderness  only  at  the  level  of  the 
musculature surrounding the neck and upper back, consistent with myofascial pain and possible 
radiculitis. The provider recommended physical therapy and did not note a plan for cervical spine 
MRI. In this case, given that the patients clinical history and examination did not suggest 
pathology that necessitated interventions beyond observation and conservative care, and as the 
records did not document a trial of appropriate conservative management prior to the imaging 
study in question, the service at issue was not medically indicated. Therefore, MRI (e.g., proton), 
spinal canal and contents, cervical; without contrast material on 8/15/22, was not medically 
necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 22-year-old male enrollee has requested reimbursement for residential mental health treatment for adults provided from 1/14/19 through 2/08/19. 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 in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation with any active intent or plan and no history of suicidality. With regards to functional status, the records support a score of 2 due to overall good functional level in treatment but consideration of functional problems, including withdrawing from school when in the community and using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of psychotic symptoms that appear under adequate control. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment. In terms of treatment and recovery history, the records support a score of 3 due to some motivation for treatment but no past significant substance use treatment mentioned in the records. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 14. This score correlates with low-intensity community-based services. Therefore, residential mental health treatment for adults provided from 1/14/19 through 2/08/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 15-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge, 2.2 mg injected. 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. This patient does not have a known hypothalamic-pituitary defect or a known deficiency of at least one pituitary hormone (other than growth hormone), which would allow the diagnosis of growth hormone deficiency without growth hormone (GH) stimulation testing. In addition, this patient does not have a medical condition for which growth hormone is strongly recommended, such as small for gestational age with failed catch-up growth. Based on this patients normal laboratory results and delayed bone age, the most likely diagnosis is idiopathic short stature. The 2008 consensus guidelines on idiopathic short stature describe a height Z score of -2 to -3 as the range to consider growth hormone therapy. Although this patients height Z score was -2.3 standard deviations below the mean at the time of growth hormone initiation, the predicted adult height of 67 to 68 inches is concordant with his mean parental height (68.75 inches). Additionally, the patient grew 2.6 cm from June 2018 to January 2019 before starting growth hormone therapy. Based on the records, the response to growth hormone therapy is likely secondary to a pubertal growth spurt. Therefore, Humatrope 24 mg cartridge 2.2 mg cartridge is not medically necessary for the treatment of this patient.