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

Summary Reviewer 2

A 33-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation (64568 and 0466T). 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 the submitted documentation fails to demonstrate the superior efficacy of the requested services. The records do not document what measures were used to make continuous positive airway pressure (CPAP) usage tolerable. There is no record of compliance studies to demonstrate the effectiveness of his CPAP usage. Further guidance and follow-up has been shown to be successful in helping patients adhere to CPAP therapy. The patient also may be a candidate for an oral appliance. Oral appliances have been shown to be highly successful for the treatment of patients with mild and moderate obstructive sleep apnea. In sum, the requested hypoglossal nerve stimulation (64568 and 0466T) is not likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 47-year-old male who presented to the emergency department with abdominal/flank pain after a surfing accident. The patient has requested reimbursement for inpatient hospital stay provided on 10/06/20. 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 at the time of admission, the patient was hemodynamically stable and afebrile with normal oxygen saturations on room air. His kidney function and hemoglobin levels were normal. The hematuria had cleared. The patient had not failed treatment as an outpatient. He did not require any urgent procedures. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patientas 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. Therefore, inpatient hospital stay provided on 10/06/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 28-year-old male enrollee has requested reimbursement for residential treatment center services from 2/1/17 through 2/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavior health condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Although addiction specialty services were indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24 hour supervised setting from 2/1/17 through 2/2/17.  Despite the patients nausea and dehydration, which necessitated a bolus of intravenous fluids and administration of an anti-emetic medication, the patient did not have a medical condition or psychiatric syndrome that warranted residential placement. The patient was working a program for his addiction and he was motivated in his treatment. The patient had safe and sober housing.  He had a supportive family.  The patient was not using drugs.  The records note that he was tolerating the medications prescribed for his detoxification and insomnia.  In sum, outpatient based treatment would have been safe and appropriate at the time. As such, the residential services from 2/1/17 through 2/2/17 were not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found that local treatment for primary uveal melanoma is effective in preventing local recurrence in over 95 percent of cases, yet up to 50 percent of patients are at risk for metastatic disease. The high risk of metastatic disease is thought to be due to a propensity for early micrometastasis followed by a variable latency period prior to the emergence of overt metastatic disease. Gene expression profiling (GEP) has been shown to be superior to chromosomal markers, as well as clinical and histopathological prognostic factors, for defining groups at high risk for the development of metastatic disease. Using primary uveal melanoma samples obtained by fine needle biopsy, GEP classifies tumors as having low (class 1) or high (class 2) metastatic potential depending on the expression of 12 discriminating genes and three control genes. This profile test is considered a standard of care. In sum, gene testing performed on 9/11/17 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: Upheld

Summary Reviewer 1 
 
A 60-year-old male enrollee has requested reimbursement for CPT 81529, which is an oncology 
(cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 
content and three housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  service  at  issue  was 
investigational for the evaluation of the enrollees melanoma. The physician reviewer found that 
the service at issue is not approved by the U.S. Food and Drug Administration (FDA) for the 
staging or treatment of melanoma. Current medical literature does not demonstrate the clinical 
utility, appropriate use, or improved outcomes for melanoma patients with the use of the service 
at issue, and there is insufficient evidence to confirm its reliability or improved outcomes in the 
staging  or  treatment  of  melanoma.  Traditional  pathologic  factors  remain  the  strongest 
independent predictors of recurrence risk. In the setting of a thin melanoma, standard therapy is 
a  wide  local  excision  followed  by  periodic  skin  examination.  The  service  at  issue  is  not 
recommended under the National Comprehensive Cancer Network (NCCN) guidelines in this 
clinical setting, and the results from the testing would not change the outcome or treatment. The 
NCCN further notes that it remains unclear whether gene expression profiling (GEP) platforms 
provide clinically actionable prognostic information. The American Academy of Dermatology 
guidelines do not report any practical benefit from the use of the service at issue in this clinical 
setting.  Therefore,  CPT  81529,  which  is  an  oncology  (cutaneous  melanoma,  mRNA,  gene 
expression profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), 
utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk including 
likelihood of sentinel lymph node metastasis, on 3/8/22, was not likely to have been more 
beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 49-year-old female with a diagnosis of alopecia areata, totalis type, present for the 
past three years. The patient has requested authorization and coverage for Xeljanz [tofacitinib 
tablets; oral solution, 10 mg (60 per 30 days)]. The Health Insurer has denied this request and 
reported that the requested medication is not medically necessary for the treatment of this patient. 
This denial is the subject of this appeal and determination. The physician reviewer found that the 
submitted documentation supports the medical necessity of the requested medication. While the 
U.S. Food and Drug Administration (FDA) does not approve the use of Xeljanz, an oral Janus 
kinase (JAK) inhibitor, for the treatment of severe alopecia areata, it does approve the use of 
Olumiant (generic name baricitinib), another oral JAK inhibitor, for the treatment of adult patients 
with severe alopecia areata. Current medical literature supports the use of Xeljanz in this clinical 
setting. Ibrahim and colleagues report that oral tofacitinib is a successful treatment for alopecia 
areata. Given that the patient in this case has been treated with Xeljanz with improvement and 
without  side  effects  since  January  2021,  the  requested  medication  is  medically  indicated. 
Therefore, Xeljanz [tofacitinib tablets; oral solution, 10 mg (60 per 30 days)] is medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 51-year-old female enrollee has requested reimbursement for hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that hyperthermia is the use of heat to kill cancer cells, which are purportedly more sensitive to high heat than normal cells. It has had some usefulness, when combined with radiation therapy, in the treatment of chest wall recurrences of breast cancer.  However, there is a lack of data that it can be used as primary therapy, without radiation, of breast cancer, as has been done in this patient. Hyperthermia alone is not beneficial in this clinical setting. Therefore, hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15 was not likely to have been of greater benefit than other treatment alternatives. 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: Upheld

Summary Reviewer 

The patient is a 59-year-old female with listed diagnoses of inflammatory polyarthropathy, osteoarthritis and fibromyalgia. She has been treated with multiple medications, including prednisone, sulfasalazine, Humira, ibuprofen and Toradol. The physician reviewer found that the submitted documentation fails to support the medical necessity of the requested medication in this clinical setting. This patient reports pain in her back, hands and feet, as well as multiple soft tissue areas. She has been treated with multiple medications to date, all of which have either resulted in side effects or a lack of response. The available medical records do not document objective findings to support the presence of an inflammatory arthritis. There is no documentation of synovitis on physical examination, nor is there documentation of radiologic studies with findings consistent with inflammatory disease. On the basis of this lack of documentation, the requested medication is not medically indicated. Additionally, there is a lack of evidence
supporting the use of H.P. Acthar Gel in fibromyalgia. Therefore, H.P. Acthar 80 unit/mL Gel is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 21-year-old male who underwent esophagogastroduodenoscopy with biopsies for a history of abdominal pain, belching, and bloating. The documentation noted a history of hypothyroidism. The physician reviewer found that according to the ASA guideline for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care may be necessary in patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures, and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. In this case, the records do not support the medical necessity of monitored anesthesia care over conscious sedation. Therefore, anesthesia services provided on 5/07/19 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 female enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment provided from 2/02/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are 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 instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. In terms of functional status, the records support a score of 2. The patient has had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment and indicated prior school functioning was good. In terms of comorbidity, the records support a score of 2. The patient does not have a history of active serious medical issues, and her prior substance use was described to be minimal. With regards to level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a strained relationship with her family and indicated some mild stress at home. In terms of level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. With regards to resiliency and treatment history, the records support a score of 3. The patient had some outpatient mental health therapy prior to her residential admission but continued to have some symptoms of anxiety and eating disorder. She had not tried or failed intensive outpatient forms of treatment for her eating disorder. In terms of acceptance and engagement of the child, the records support a score of 2. The patient has participated in therapy. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, mental health residential treatment from 2/02/19 forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 54-year-old male with a history of left hip pain of two years duration. The pain limits his physical activities including jogging and walking. The pain is anterolateral. There is some intermittent catching. He has tried and failed conservative treatment including physical therapy. On examination, there is a slight antalgic limp. The record notes that his hip range of motion is slightly limited. There is a positive McCarthys sign. FADIR impingement sign is also positive. X-rays show CAM type femoroacetabular impingement. The magnetic resonance (MR) arthrogram dated 9/7/17 showed long standing CAM type femoroacetabular impingement with labral damage. The osteoarthrosis is associated with a subchondral cyst in the acetabulum. The alpha angle is 73 degrees. There is a labral tear as well. The patient reports that he does not want a hip replacement. The provider indicates that the patient meets criteria for arthroscopy of the left hip, labral repair versus debridement and femoroplasty. The Health Insurer has denied the requested services as not medically necessary for the treatment of the patient. This denial is the subject of this appeal and determination. There is support in the medical literature for the requested services in this clinical setting. Femoroacetabular impingement is an important cause of labral tears, chondral lesions, hip pain and a leading cause of early osteoarthritis.  Different surgical techniques for the management of femoroacetabular impingement have evolved rapidly over the last decade. The aim of surgery is to correct symptomatic CAM and Pincer abnormalities and reduce secondary osteoarthritis early on; thereby preventing progressive osteoarthritis, while minimizing complications associated with surgery. The medical data indicates that arthroscopic technique has a low complication rate. In this case, the patient has labral tears, CAM type femoroacetabular impingement and early to moderate degenerative changes. The physical findings and MR arthrogram confirm the femoroacetabular impingement and associated damage. The patient has reported gradual worsening of his symptoms. The provider believes that correcting the femoroacetabular impingement with femoroplasty and possibly repairing the torn labrum will likely help the symptoms and slow down the progression of osteoarthritis. A review of the recent medical literature supports the requested services in this patients case. As such, arthroscopy of the left hip, labral repair versus debridement and femoroplasty have been demonstrated as medically necessary for the treatment of this patients medical condition. Therefore, based on the reasons stated above, the requested services are medically necessary for the treatment of this patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that there is a lack of evidence based studies supporting the superior efficacy of the services at issue. The medical literature does not demonstrate that DaT SPECT scan can offer clinical decision making relative to treatment management options in this clinical setting. There remains issues of sensitivity and specificity relative to DaT scans in the diagnosis of Parkinsonian tremor versus other etiologies.  Therefore, in this patients case, DaT SPECT performed on 8/24/16 was not likely to be more efficacious than other standard options for the evaluation of this patient. Based upon the information set forth 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
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for residential substance use disorder treatment services provided from 8/16/15 through 9/27/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found this patient had a very serious polysubstance addictive illness complicated by the co-occurring diagnoses of generalized anxiety disorder and major depressive disorder in context of enduring characterological issues.  Despite prior treatment interventions, the patient was unable to sustain any meaningful sobriety.  Her substance use dominated all functional domains and necessitated a complicated detoxification.  She had a strained relationship with her significant other and her parents.  Despite her impaired insight, the patient was motivated for treatment. Based on the longitudinal history and medical documentation, the patient would have promptly relapsed and required re-admission in the absence of residential programming. Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Additionally, the services provided during the disputed timeframe were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness.  Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically necessary for treatment of the patients behavioral health condition.Therefore, 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 3


The parent of a 15-year-old male enrollee has requested reimbursement for Afirma gene testing provided on 6/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al).  Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). A relatively new test, the Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick, et al). All told, the testing at issue 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.