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

Summary Reviewer 


A 52-year-old female enrollee has requested reimbursement for anesthesia services performed on 7/27/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, anesthesia services performed on 7/27/15 were not medically indicated 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 2/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of osteoporosis.  The physician reviewer found that markers of bone turnover, such as the collagen crosslinks, have been recognized by experts in osteoporosis as a tool to evaluate osteoporosis from diagnostic and therapeutic standpoints. There are multiple articles that show the value of this test with anabolic agents, such as Forteo. Antiresorptive agents decrease and anabolic agents increase the markers of bone turnover. These markers are useful to determine adherence and efficacy of therapy. Collagen crosslinks are also important in the diagnostic evaluation of osteoporosis that has failed to respond to treatment. This patient has received antiresorptive therapy in the past, so it was important to obtain markers of bone turnover. This testing allows the provider to assess the effectiveness of therapy and patient compliance. In this patients case, the services at issue were an important component of monitoring therapy.  In sum, laboratory testing (collagen crosslink testing) performed on 2/25/17 was 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 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 2


A 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found based on the documentation provided for review, Botox injections are supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient has a diagnosis of chronic migraine, with reported baseline of more than 15 headache days per month of severe headaches. She has been on multiple preventives, and multiple abortives. The records indicate a robust improvement with Botox at appropriate doses. In addition, Botox therapy is proven for chronic migraine, and in this patient, has been successful, while prior standard therapies have been unsuccessful. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 24-year-old transgender female enrollee has requested reimbursement for breast augmentation performed on 6/7/17. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the medical necessity for breast augmentation in transgender females with gender dysphoria is a case specific determination. This patient is well documented to have gender dysphoria. The medical literature supports breast augmentation in male to female patients as part of gender reassignment surgery. In this patients case, based on her diagnosis and history, her external anatomy should be more consistent with a female rather than a male.  Her examination detail and the photographs support that she has had insufficient breast development despite hormonal therapy. Thus, prior to the procedure, her breasts were more consistent with a male chest contour. Preoperative photographs show evidence of minimal breast development, consistent with her history. Since the condition did not resolve with hormone therapy, surgical intervention to treat this patients gender dysphoria was medically reasonable and appropriate. As such, the surgical breast augmentation performed on 6/7/17 was medically necessary for the treatment of this patients gender dysphoria. Therefore, for the reasons stated above, the procedure at issue was medically necessary. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA).The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy surgery or radiation and may be followed closely instead. The important features to recognize are Gleason score and PSA but these are imperfect. Thus, current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Prostate Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (Cooperberg, et al; Eastman; Knezevic, et al). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. In addition, the National Comprehensive Cancer Network (NCCN) guidelines suggest the Oncotype DX test to better stratify such patients with localized disease. For the reasons provided, the Oncotype DX testing provided on 9/15/15 was 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 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 2

The patient is a 41-year-old male with a history of migraines. Headaches vary in location from frontal to lateral. The quality of the headache is described as throbbing with moderate to high severity. The patient has tried several prophylactic therapies which have failed to control his headaches. He has requested reimbursement for Botox injections provided on 10/16/17 and 1/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.  Botox is a tool in the management of chronic migraine which has shown effectiveness. Repeated onabotulinumtoxinA treatments have been shown to be safe and well-tolerated. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. This patient fits the criteria for chronic migraine. He has failed a number of accepted preventable therapies, including medications within the anti-hypertensive, antiepileptic, and antidepressant classes. In sum, Botox injections provided on 10/16/17 and 1/08/18 were likely to have been superior over other treatment modalities. 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 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. The medical literature has noted the efficacy of intravenous immune globulin for the management of chronic inflammatory demyelinating polyneuropathy. In this patients case, other options, such as corticosteroids, would not be advisable due to greater adverse side effect profile and potential of causing steroid induced myopathy. Eftimov and colleagues showed that the benefit of intravenous immune globulin persisted for 24 and possibly 48 weeks. In the study by Hughes and colleagues, intravenous immune globulin was shown to reduce functional disability and significantly improved grip strength in patients with chronic inflammatory demyelinating polyneuropathy. Therefore, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1
I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male who complains of lumbar pain that started in 2012 after hot yoga. He had increasing back pain on and off over the last several years and has tried two facet injections, with no relief. The patient reported that a zero gravity chair is beneficial, and Kenalog injections reportedly provide temporary relief. The patient has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.

The current medical evidence has not demonstrated the superior efficacy of the services at issue. There is a lack of support for continuous or intermittent traction as a single treatment for patients with low back pain with and without sciatica. Clarke and colleagues noted, traction for patients with sciatica cannot be judged effective at present either, due to inconsistent results and methodological problems in most studies. Therefore, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 was not likely to have been of greater benefit than other available treatment options. 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 50-year-old female enrollee has requested reimbursement for the lumbar injections provided on 5/28/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain, right lower extremity pain with and concomitant neurological deficits.  The physician reviewer found that in the documentation available for review, this patient meets the medical necessity criteria for the lumbar injections provided on 5/28/15. Specifically, the patient presented with radicular pain associated with symptoms of nerve root irritation and low back pain due to disc extrusions and/or contained herniations. Further, the patients pain had been unresponsive to conservative treatment, including pharmacotherapy and exercise. The literature supports the use of epidural steroid injections in this clinical setting. Therefore, the lumbar injections provided on 5/28/15 were medically necessary for treatment of this patients medical condition. Accordingly, 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: Overturned

Summary Reviewer 2


A 54-year-old male enrollee has requested reimbursement for radiofrequency neurolysis performed on 4/08/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected.  In reviewing the medical records, imaging is significant for multilevel spondylosis.  The physical examination is also significant for facet mediated pain.  Per the providers notes, the patient experienced long-term relief with previous radiofrequency facet ablation at the same level below the fusion.  In sum, radiofrequency neurolysis performed on 4/08/16 was likely to have been of greater benefit than other treatment alternatives.  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: Upheld

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, for dates of service 2/07/19, 2/09/18, 2/12/19, 2/14/19, 2/19/18, 2/21/18, 2/26/18, 2/28/18 and 3/05/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence has not demonstrated the superior efficacy of the services at issue. In this clinical setting, radiation has not been proven to be superior or more beneficial as compared to surgical resection. The claim that radiation leads to less scarring has not been rigorously studied in a prospective setting. Radiation carries a risk for second malignancy and permanent skin changes.  In sum, high dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, for dates of service 2/07/18, 2/09/18, 2/12/18, 2/14/18, 2/19/18, 2/21/18, 2/26/18, 2/28/18 and 3/05/18 was not likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 61-year-old female enrollee has requested reimbursement for mental health inpatient treatment provided from 9/03/14 through 10/15/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found the patients affective illness and anxiety burden was complicated by a poorly defined self-concept and treatment non-adherence, the confluence of which contributed to, if not fueled, a recurrent symptom complex.  Per the medical records, the patient was not experiencing an acute psychiatric syndrome.  She was not suicidal, homicidal, psychotic or gravely disabled.  She was able to independently complete activities of daily living.  The record did not demonstrate that the patient had failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program or even consistent outpatient services, during the episode of illness.  Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  However, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient.  Thus, mental health inpatient treatment provided from 9/03/14 through 10/15/14 was not medically indicated 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. 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 that the current medical evidence does not support the services at issue in this clinical setting. The patient likely had a viral exanthem. He is treated with an antibiotic for presumed strep infection. The records do not support a clinical reason for ordering PCR testing. The treatment would not change based on this testing. Therefore, PCR testing performed on 8/03/17 was not likely to have been superior over 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 3 
 
A 69-year-old female enrollee has requested reimbursement for Guardant 360 testing performed 
on 1/11/21. 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 therapy of advanced non-small cell lung cancer has been revolutionized 
by the finding of EGFR mutations in certain adenocarcinomas. Even if stage IV disease is present, 
therapy targeted to EGFR with erlotinib results in prolonged survival when compared with 
standard chemotherapy regimens. In this case, it was important to know whether the patient 
had developed an EGFR T790M mutation. This mutations confers resistance to erlotinib. A liquid 
biopsy was ordered to analyze for this mutation. The Guardant 360 test is commonly referred to 
as a liquid biopsy since it involves sampling of tumor cells that may be circulating in the peripheral 
blood. The NCCN guidelines note that the test is acceptable if the patient is unfit to pursue more 
invasive methods for tumor sampling. If a simple core biopsy of an accessible metastatic lymph 
node, like a supraclavicular or axillary lymph node was feasible, then a Guardant 360 would have 
been unreasonable; but that is not the case here. It was reasonable to have the Guardant 360 
test done since disease is inaccessible. Therefore, Guardant 360 testing performed on 1/11/21 
was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for the Oncotype DX colon cancer assay performed on 10/9/14. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees colon carcinoma. The physician reviewer found that presently, medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer but not for those with stage II disease (Gray, et al). Meta-analyses have not shown any survival advantage for 5-FU/leucovorin treatment in stage II patients but the reasons for these findings are complex. The benefits for stage III patients are significant and it is likely that stage II patients benefit as well (Figueredo, et al). Therefore, subset analyses to identify patients with prognostic features that may predict for chemotherapy benefit have been analyzed (Benson, et al). The Oncotype DX test uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence (OConnell, et al). The test was validated independently in the QUASAR trial as an excellent prognostic indicator (Gray, et al). Consistent with this support, the Oncotype DX colon cancer assay performed on 10/9/14 was medically necessary for evaluation of this patients colon cancer. In conclusion, the testing at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Actemra provided from 7/14/15 through 12/15/15 and ongoing. The Health Insurer has denied this request indicating that the medication at issue was and is investigational for the treatment of the enrollees medical condition.  The physician reviewer found that Actemra was not and is not likely to be more beneficial for treatment of the patients medical condition than other modalities. There is a lack of support in the peer-reviewed literature for Actemra in this clinical setting. At this time there is a lack of literature supporting tocilizumab for the treatment of patients post-transplant. In addition, the records do not indicate that the patient has tried treatment with bortezomib, which does have reports in the peer-reviewed literature. Given the above, the medication at issue was not and 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 medication at issue was not and 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.