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

Summary Reviewer 2 
 
A 43-year-old male enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve first two bodies, lumbar or sacral. 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 current medical 
literature supports the use of the requested procedure in leading to statistically significant 
improvement over continuation of standard treatment. Fischgrund and colleagues report that 
patients treated with radiofrequency ablation of the basivertebral nerve for the treatment of 
chronic back pain maintained benefits at two years following treatment in both Oswestry 
Disability Index (ODI) and Visual Analog Scale (VAS). The requested procedure is more effective 
than continued conservative care particularly in the setting of Modic endplate changes as seen 
on this patients MRI. Therefore, thermal destruction of intraosseous basivertebral nerve first 
two bodies, lumbar or sacral is likely to be more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 59-year-old male who sustained left ear trauma while riding his bicycle. The patient has requested reimbursement for otoplasty performed on 10/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted photographs document left facial trauma. Post-acute photographs show a missing left earlobe, and photographs post repair show a natural looking earlobe on the left side. No other ear deformity is seen. Per the records, the patient underwent reconstruction of a partially avulsed left earlobe with release of the left ear scar contracture, adjacent tissue transfer, and full thickness skin graft. Hendricks and colleagues stated, aProminent ears are by far the most common congenital ear deformity. Many techniques have been described using one or a combination of three basic methods: cartilage cutting, cartilage weakening and pure cartilage shaping techniques. The ideal otoplasty technique should yield a natural correction of the deformity, with low recurrence rates and with little risk of complications.a Otoplasty is considered in the medical literature to refer to correction of a variety of causes of prominent ears. In this patientas case, there was no report of prominent pinna or corrected deformity of the pinna in the medical information received for review. Therefore, the otoplasty performed on 10/14/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus. The physician reviewer found that treatment for this patients left eye with corneal collagen cross-linking provided on 7/21/16 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the patients vision loss and stage of keratoconus, the cross-linking was the most appropriate and effective treatment available. Overall, collagen cross-linking has been shown to be a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. For these reasons, the left eye corneal collagen cross-linking provided on 7/21/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of an eight-year-old male enrollee has requested authorization and coverage for Omnitrope (somatropin) 100 mg cartridge, 0.8 mg per day. 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 supports the requested medication in this clinical setting. 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 stimulation testing.  In addition, this patient does not have a medical condition for which growth hormone is strongly recommended, such as chronic renal insufficiency, IGF-1 deficiency or Prader-Willi syndrome. Although increasing numbers of patients with Noonan syndrome are receiving growth hormone therapy, this patient does not meet the diagnostic criteria for Noonan syndrome and has not seen a geneticist to confirm the diagnosis.  Based on this patients normal laboratory results and delayed bone age, the most likely diagnoses are idiopathic short stature, constitutional delay and familial short stature (or a combination of these). The 2008 consensus guidelines on idiopathic short stature are most relevant and includes no clear biochemical criteria for initiating growth hormone therapy and no requirement for growth hormone stimulation testing. This patients consistently low height standard deviation and predicted final adult height support the use of recombinant growth hormone therapy in this case. Therefore, Omnitrope (somatropin) 100 mg cartridge, 0.8 mg per day is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested reimbursement for air ambulance transportation provided on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has a history of spinal muscular atrophy.  The physician reviewer found that this patient has a diagnosis of spinal muscular atrophy. She had acute respiratory failure on 11/16/17, necessitating admission to Cottage Health Hospital. During the course of her admission, the patients family made inquiries regarding transferring the patient to a facility with more expertise in treating patients with spinal muscular atrophy. By 12/19/17, the patient had been weaned from a ventilator to a tracheostomy collar. The patients family requested the patient be transferred to Rutgers University Hospital to the care of a specialist in spinal muscular atrophy where studies had been conducted to determine appropriate respiratory protocol and management strategies. However, the records do not demonstrate that this patient required emergent air ambulance transportation. The patient was hemodynamically stable. She had already been weaned to a tracheostomy collar. Although the provider at Rutgers University Hospital had conducted research with spinal muscular atrophy patients, there is a lack of evidence to support that this patient required a higher level of care at the time of her transfer. It appears the transfer was initiated at the request of the patients family. The documentation submitted does not support that this patient required emergent air ambulance transportation to receive medically necessary higher level of care at the closest hospital capable of providing such services. Thus, air ambulance transportation provided on 12/20/17 was 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: Upheld

Summary Reviewer 

A 63-year-old female enrollee has requested authorization and coverage for Forteo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. The physician reviewer found that this patient has severe osteoporosis and multiple gastrointestinal issues. However, the medical records fail to demonstrate evidence of kidney disease or any pending dental issues or plans for major dental work.  She is reported to have small bowel dysmotility, celiac disease, and colonic inertia and unable to take oral bisphosphonates. There is no history of contraindication to bisphosphonates or chronic kidney disease. Given her history, the current guidelines would recommend intravenous bisphosphonates (zoledronic acid) as the preferred agent for this patient. Reclast or zoledronic acid is preferred if oral bisphosphonates cannot be tolerated. Prolia is a recommended alternative in this patients case. Reclast would be would be an option in this case given her normal renal function, Candidates for teriparatide include those with severe osteoporosis and are at high risk for fracture (T-score of -3.5 or below without fractures; T-score of -2.5 or below plus a fragility fracture), those who cannot tolerate bisphosphonates or who have relative contraindications to oral bisphosphonates (achalasia, scleroderma esophagus, esophageal strictures) and those who have failed other osteoporosis therapies. In this patients case, she does have evidence of severe osteoporosis and has reported that she cannot take oral bisphosphonates. However, the records do not show that she has tried other therapies like Reclast or Prolia.  As such, Forteo is not medically necessary for treatment of this patient. The Health Insurers denial should be upheld. Therefore, for the reasons stated above, 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: Overturned

Summary Reviewer 2


A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Electromagnetic navigational bronchoscopy is a unique tool that allows the provider to accurately guide bronchoscopic tools to predetermined points within the tracheobronchial tree.  With this system, the provider can accurately guide the steerable extended working channel to a suspicious peripheral lesion for diagnostic testing.  The alternatives to electromagnetic navigational bronchoscopy biopsy include standard/blind bronchoscopy or computed tomography (CT) guided biopsies.  While CT guided biopsies have a superior diagnostic yield of 90%, they are limited by complications, both pneumothoraces and hemoptysis.  Electromagnetic navigational bronchoscopy has a track record of excellent diagnostic yields, low complication rates and acceptance within the medical community as a useful test of the diagnosis of a peripheral lesion.  Based on the medical records, this patient was a candidate for electromagnetic navigational bronchoscopy based on the lesion size, location and shape, especially in light of his smoking history.  In sum, electromagnetic navigational bronchoscopy performed on 9/29/15 was likely to have been superior over 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 3 
A 59-year-old female insured has requested authorization and coverage for Rinvoq 45 mg tablets 
(30 tablets every 30 days). The Health Insurer has denied this request indicating that the requested 
medication is considered investigational for the treatment of the insured's Chron's disease. 
The physician reviewer found that comparing Rinvoq 45 mg with placebo for patients with 
moderate-to-severe Chrons disease, Rinvoq resulted in higher clinical remission rates at 12 weeks 
(Loftus, et al.). Moreover, Rinvoq is FDA-approved for patients with moderate-to-severe Chrons 
disease who have not responded to anti-tumor necrosis factor (TNF) therapy. The records reflect  that this patient presents with a long history of Chrons disease. While the patient is medically 
stable, she is not optimally treated on her current regimen, which has significantly affected her 
quality-of-life. Rinvoq is FDA-approved and supported by the medical literature for the treatment 
of patients with Crohn's disease. For these reasons, the requested Rinvoq 45 mg tablets (30 tablets 
every 30 days) are likely to be more beneficial for the treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 52-year-old male with asthma. The patient has requested authorization and coverage for Nucala auto injector pen.  The physician reviewer found that Nucala is U.S. Food and Drug Administration (FDA) approved and supported by the medical evidence for the management of severe asthma in adults with an eosinophilic phenotype of asthma. Based on the available information, it is fair to characterize the phenotype of the patientas asthma as eosinophilic, based on an elevated peripheral eosinophil count of 180. It is important to note that peripheral eosinophils were elevated while the patient was taking systemic steroids, which is quite remarkable, as steroids typically drive down eosinophils. This information demonstrates that an eosinophilic process was at play. There is sufficient support for the requested medication in this clinical setting. Therefore, Nucala auto injector pen is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. 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 interspinous spacers were developed to avoid the risks of a traditional laminectomy via a less invasive technique that is reversible. The device is placed percutaneously in the interspinous space with minimal disruption of the spinal anatomy. The goal is to limit extension of the spine, minimizing the effects of spinal degeneration and enlarging the spinal canal and neural foramina area. This patient is being treated for lumbar spinal stenosis with neurogenic claudication. While there are many interspinous devices on the market, none have high quality research to demonstrate superiority over the current standard of care, simple decompression. The use of an interspinous spacer for spinal stenosis as a minimally invasive, stand-alone procedure has shown high failure and complication rates.  Until data exists that demonstrate noninferiority of these devices to the current gold standard treatment, simple decompression, the use of the requested device as a standalone procedure should be considered investigational for the treatment of the patients condition. In sum, the requested surgical insertion of an interspinous process spacer is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg 
tablets (two tablets per day). The Health Insurer has denied this request indicating that the 
requested medication is considered investigational for treatment of the insureds urothelial 
carcinoma. The physician reviewer found that the use of next-generation sequencing (NGS) panel 
testing as a means to select anticancer therapies in the treatment of patients with advanced 
cancer has been advancing over the past few years. Once identified, a specific therapy can be 
given to the patient directly treating their tumor. In this patient, NGS based molecular testing 
demonstrated  EGFR  exon  19  mutation  and  FGFR2  amplification.  The  U.S.  Food  and  Drug 
Administration (FDA) approved Balversa for use in the setting of FGFR2/3 alteration metastatic 
bladder/urothelial cancer. This patient has been treated with multiple lines of therapies including 
EGFR targeted agents and chemotherapy. She has also been treated with liver directed therapies. 
The patient was recently started on combination therapy with Tagrisso and Balversa. The 
provider noted that the patient has responded well to this combination treatment reflected with 
a decreasing tumor marker (CEA). A phase II clinical study also demonstrated the benefits of 
Balversa in the treatment of patients with metastatic solid tumors with EGFR 2/3 alterations 
(Loriot, et al.). As such, the requested Balversa 4 mg tablets (two tablets per day) is not likely to 
be more beneficial for treatment of the patients medical condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 52-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator provided on 1/24/19. The Health Insurer has denied this request indicating that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient had a recent myocardial infarction and underwent acute revascularization with coronary stenting. His subsequent ejection fraction was below 35%, and his medical management was being optimized. In this situation, a permanent automatic implantable cardioverter-defibrillator is not indicated until three months have passed after revascularization if the ejection fraction remains less than 35%. However, he was at increased risk for sudden death during this period. Medical therapy was also being optimized to improve left ventricular function during this period. A wearable cardioverter defibrillator can provide temporary protection from early sudden death due to arrhythmia in this patient population during this interim period. The medical evidence supports the device at issue in this clinical setting. Therefore, the wearable cardioverter defibrillator provided on 1/24/19 was likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 26-year-old female enrollee has requested reimbursement for bilateral breast implant removal performed on 5/7/15. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees capsular contracture of breast implant. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the procedure at issue. According to Handel and colleagues It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation. In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. In this case, the patient underwent SERI implant removal. However, the documentation submitted for review fails to demonstrate the patient had a current infection, seroma or other functional problem that would necessitate implant removal. In addition, the patient stated that she had severe pain, but this is not supported in the medical documentation provided for review. As such, based on the documentation submitted for review, the SERI scaffold removal was not medically necessary in this clinical setting. For the reasons provided, the bilateral breast implant removal performed on 5/7/15 was 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 42-year-old female who is requesting reimbursement for fetal chromosomal analysis via cell-free DNA. The records document advanced maternal age and history of prior miscarriages. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy, is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. This is the case for both younger women and for women of advanced maternal age. This test is less invasive, with less risk to the pregnancy. Therefore, fetal chromosomal microdeletions genomic sequence analysis (81422) performed on 7/09/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. 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 enlarged lymph nodes. The physician reviewer found there is a lack of support in the medical literature for the services at issue in this clinical setting. The medical literature indicates that Epstein-Barr virus (EBV) is the main etiology of infectious mononucleosis syndrome associated with lymphadenopathy. The main methods of evaluation include PCR testing and testing by ELISA for the viral capsid antigen. Quantitative PCR testing may be indicated for the following EBV evaluations: EBV viral load, to monitor for EBV viral replication in hematopoietic stem cell and solid organ transplant recipients. More frequent testing is worth considering if the EBV load is rising. However, for standard risk individuals, as this patient, testing should be done only when they are suspected to have EBV infection. The submitted documentation does not support that this patient had a medical indication to have warranted the PCR testing. Accordingly, PCR testing provided on 5/30/17 was not likely to have been of greater benefit than the standard therapy available for evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.