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

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. 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 submitted documentation supports the superior efficacy of the services at issue. Reginster and colleagues noted that there are consistent data showing that short-term changes in biochemical markers of bone turnover may be significant predictors of future changes in bone mineral density or fracture reduction, hence suggesting that bone turnover markers play a significant role in the monitoring of anti-osteoporosis therapy. The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis. It is used as a guide to monitor compliance and efficacy of treatment. It also helps to identify non-responders that require additional work-up for other causes of osteoporosis. Thus, collagen crosslinking test (CPT 82523) performed on 9/07/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 34-year-old male enrollee has requested authorization and coverage for computed tomography (CT) of the abdomen and CT of the chest (74178 and 71270). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is agreement by the National Comprehensive Cancer Network, which noted, A PET-CT scan should be performed to confirm complete remission (CR). Patients in CR should receive clinical follow-up with a history and physical examination and laboratory studies (e.g., complete blood cell count, comprehensive metabolic panel, lactate dehydrogenase level) every three to six months for five years and then yearly or as clinically indicated. Imaging studies (CT scan) should be performed no more often than every six months for two years after the completion of treatment, and then only as clinically indicated. Considering these many studies and advising bodies, the requested services are not medically indicated. Therefore, CT of the abdomen and CT of the chest (74178 and 71270) are not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 1 
 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The physician reviewer found that American Institute of Ultrasound Medicine (AIUM) notes that 
detailed obstetric ultrasound examination is not intended to be the routine ultrasound examination 
performed for all pregnancies. Rather, the AIUM notes that it is an indication-driven examination 
performed for a known or suspected fetal anatomic abnormality, known fetal growth disorder, 
genetic abnormality, or increased risk for a fetal anatomic or genetic abnormality or placenta 
accreta spectrum. The Society for Maternal-Fetal Medicine (SMFM) notes that the performance 
of the detailed fetal anatomic examination should be rare outside referral practices with special 
expertise in the identification and diagnosis of fetal anomalies. In this case, notes dated 6/2/22 
reported a body mass index of 28 kg/m2, the demise of a dichorionic twin at seven weeks, and the 
finding of a uterine synechia. However, these are not indications that the more detailed fetal 
ultrasound  at  issue  was  likely  to  be  beneficial  than  standard,  routine  ultrasound  screening 
Therefore, ultrasound and reading of the ultrasound on 8/2/22 was not likely to have been more 
beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 36-year-old female enrollee has requested reimbursement for gene testing (MaterniT21 Plus) performed on 2/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found the methods for fetal aneuploidy detection involve either invasive technique that place the fetus at risk or non-invasive prenatal testing which uses cell free fetal DNA from the plasma of pregnant women.  Cell free fetal DNA testing is an option that can be used as a primary screening test in women at an increased risk of aneuploidy.  However, the accuracy of screening for aneuploidy is limited in multiple gestation pregnancies.  The data regarding the performance of cell free DNA screening in two gestations are limited.  Thus, gene testing (MaterniT21 Plus) performed on 2/03/15 was not likely to have been more effective 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: Upheld

Summary Reviewer 2

A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that the medical records indicate that the patient has had previous lumbar fusion surgery. Currently, there is a lack of documentation of sacroiliac joint instability, fracture, or tumor. For this reason, the criteria for sacroiliac joint fusion have not been met. Further, long-term outcomes and complications are not well-defined for use in this clinical setting. Given these findings, the requested sacroiliac joint fusion is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 29-year-old female enrollee has requested authorization and coverage for compound medication of sirolimus cream 1%. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollee, who has Klippel Trenaunay syndrome. The physician reviewer found that the current medical evidence supports the requested medication in this patients case. The documentation noted venous malformations associated with bleeding and lymphatic drainage. She has had treatment previously with laser, interferon and sclerotherapy, without improvement. There is evidence in the medical literature indicating that sirolimus, both topical and oral, is effective for these symptomatic vascular lesions. This patient has a rare condition, and there is a lack of other treatment alternatives available. In sum, compound medication of sirolimus cream 1% is likely to be superior over other treatment options. Based upon the information set forth above, the requested medication 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for residential substance use disorders treatment provided from 5/4/15 through 5/19/15. 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 due to the lengthy history of drinking and increased yet inconsistent reports of consumption, a residentially based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice. However, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of 5/4/15. There is no evidence of the emergence of any late alcohol withdrawal symptomatologies. It appears that benzodiazepine medication, a common treatment for alcohol withdrawal, was last administered on 4/24/15.  Laboratory analysis revealed mild elevation of hepatic enzymes and a slightly elevated mean corpuscular volume on 4/26/15. Such findings of transaminitis and macrocytosis are not uncommon in drinkers and often resolve rather promptly with sobriety, which is what occurred in this case. Despite the diagnoses of gastroesophageal reflux disease and seasonal/environmental allergies, the patient had an unremarkable physical examination on 4/27/15.  The presence of depression, and anxiety dating back to childhood, were significant but not generating a psychiatric syndrome that warranted treatment in a residential setting. In addition, the patient participated in therapeutic programming which helped erode her treatment ambivalence. On 5/4/15, she had a willingness to participate fully in treatment. Finally, the patient had a safe residence. Her family was described as supportive. She identified two close friendships during her psychosocial assessment. She was motivated for care. Despite the diagnoses of depression anxiety, the patient had no safety concerns. She had no prior history of chemical dependency treatment in a less restrictive setting such as anti-craving medication, community programming, outpatient specialty care, intensive outpatient services or partial hospitalization. There was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the residential rehabilitation services at issue were not medically necessary for treatment of the patients medical condition. 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 2

A 26-year-old male enrollee has requested reimbursement for cervical discography injection provided on 6/25/20. The Health Insurer indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that neck pain in patients with clinical evidence of radiculopathy or myelopathy can be easily localized by clinical, electrodiagnostic, and imaging evidence and treated by anterior cervical surgery. Cervical discography is indicated when the pain is discogenic, but the imaging studies do not show a herniation or localized cervical spondylosis. Discography can localize the pain source by distinguishing between the painful, symptomatic discs from the asymptomatic non-painful discs. Discogenic neck pain alone without evidence of cervical disc herniation or cervical spondylosis constitutes a significant percentage of patients with chronic neck pain who are resistant to conservative treatment, as in this case. For patients who continue to have refractory neck pain and fail to respond to conservative treatment, anterior cervical fusion surgery or artificial cervical disc replacement may be a better choice, and preoperative cervical discography can guarantee that the pain source will be addressed, resulting in an excellent surgical result. Therefore, cervical discography injection provided on 6/25/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 54-year-old male has requested reimbursement for Anser VDZ test provided on 7/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that Entyvio (vedolizumab) is a humanized monoclonal antibody. This medication is specifically indicated for adults with moderately to severely active ulcerative colitis or Crohns disease who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroid. Entyvio is indicated to induce and maintain clinical response/clinical remission, achieve corticosteroid-free remission and improve the endoscopic appearance of the mucosa. Contemporary literature supports that vedolizumab response, and its long-term effectiveness, are not based on drug-antibody titers, but on clinical factors.  At this time, 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 this patients case, he was not experiencing significant gastrointestinal symptomatology at the time of the testing. In sum, the records fail to establish the superior efficacy of the Anser VDZ test provided on 7/17/17. 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 2

The parent of a 14-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 10/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the testing at issue was likely to be more effective for this patient than other available treatment options. Monitoring of both serum drug levels of infliximab as well as antibodies to infliximab have been recognized as crucial elements in maintaining long-term success and has been shown to improve the health of patients by preserving response to infliximab. A study by Gisbert and Panes noted cumulative loss of response to infliximab in approximately 13% of patients per year. In this case, a question was raised regarding whether the patients clinical symptoms were suggestive of loss of response to infliximab or some other cause, and subsequent notation reveals that the results of the test were interpreted to the benefit of the patient by leaving the pre-test dosing schedule unchanged. In this clinical setting, drug level monitoring 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: Upheld

Summary Reviewer 2

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 the Life Vest wearable defibrillator is a U.S. Food and Drug Administration (FDA) approved device for prevention of sudden cardiac death for patients at increased risk for life threatening arrhythmias, ventricular tachycardia and ventricular fibrillation. However, the efficacy of the Life Vest for specific groups of patients is still being determined. For patients with acute heart failure, such as the patient in this case, the usefulness of the device is still being evaluated (Klein, et al). Zishiri and colleagues reported data that support the use of the Life Vest wearable defibrillator in the post-myocardial infarction phase, or immediately post-revascularization after myocardial infarction, which is not the case for this patient. Moreover, this patient does not meet current indications for an implantable cardioverter defibrillator, which may support an indication for the Life Vest. He has a newly diagnosed non-ischemic cardiomyopathy, possibly tachycardia-induced, due to rapidly conducted atrial flutter. All told, the current peer-reviewed medical literature does not indicate the Life Vest provided to this patient on 1/20/14 was likely to have been 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 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 55-year-old female enrollee has requested authorization and coverage for bariatric surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees morbid obesity. The physician reviewer found that submitted documentation supports the medical necessity of the requested services in this patients case. This patient meets the standard criteria for bariatric surgery, including the American Society for Metabolic and Bariatric Surgery criteria. The patient has a body mass index which is greater than 35 kg/m2. Specifically, the records documented a body mass index of 60.53 kg/m2. The patient has more than one comorbid condition related to obesity. The patient has completed a multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers. Medical clearance, support and attestation of prior failed weight loss efforts were provided. The medical evidence supports the requested services in this clinical setting. Thus, the requested bariatric surgery is medically necessary for the treatment of this patient. Therefore, the requested services are medically necessary for treatment 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 for an endoskeletal left transtibial prosthesis provided on 1/03/19. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has requested reimbursement for a microprocessor controlled foot/ankle. There are many studies that discuss the use of a microprocessor controlled foot/ankle. Many of the studies described some improvement in physiologic/kinematic parameters, such as residual knee moment, increased stance phase dorsiflexion, and vertical ground reaction forces. However, these studies did not identify how these improvements translated into real world functional benefit, such as improved walking endurance, reduction in falls/instability, or reduction in skin friction/breakdown on the residual limb. The physiologic/kinematic benefits do not always correlate with clinical improvement. Hahn and colleagues noted, aWhile the perception of benefits regarding the negotiation of uneven terrain and slopes is very high, the correlation to product preference is moderate.a Users identified 80-90% improvement with walking on uneven ground, ascending, and descending ramps. However, only 40% of users preferred the microprocessor controlled foot. As such, it can be difficult to extrapolate findings regarding isolated physiologic/kinematic benefits to patient preference, let alone extrapolating that data to sustained functional improvement. As another example, many of the studies focused on an isolated point in time intervention in a gait lab or other clinical setting. As such, these studies had participants perform tasks in a clinical setting and did not evaluate whether the use of this device in a real world home setting would offer similar functional gains. Patients frequently have unexpected responses to adaptive equipment, as evidenced by a study by Lamers and colleagues. This study demonstrated that despite the microprocessor-controlled ankle behaving similarly for each user, there were marked differences in individual responses. The authors noted, aFor instance, two users switched from a forefoot landing pattern with the microprocessor-controlled ankle locked at neutral angle to rearfoot landing when the microprocessor-controlled ankle adapted to the slope, while two maintained a forefoot and three maintained a rearfoot landing pattern across conditions.a As such, it can be difficult to extrapolate benefits from a clinical setting to the real world day-to-day environment. Thus, the endoskeletal left transtibial prosthesis provided on 1/03/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 64-year-old male insured has requested reimbursement for laboratory testing performed on 
5/13/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds acute deep vein thrombosis (DVT). The 
physician reviewer found that currently recommended indications for thrombophilia testing 
include  idiopathic  or  recurrent  venous  thromboembolism,  a  first  episode  of  venous 
thromboembolism at before 40 years of age, a family history of venous thromboembolism, 
venous thrombosis in an unusual vascular territory, and neonatal purpura fulminans or warfarin-
induced skin necrosis (Nakashima and Rogers). As noted in the medical literature, when two or 
more  of  these  thrombosis  characteristics  are  present,  thrombophilia  testing  should  be 
considered. In this patients case, the patient meets only one of the requirements in that he has 
a possible idiopathic unprovoked deep vein thrombosis. However, in the absence of a family 
history  concerning  for  a  familial  hypercoagulable  state,  Factor  V  Leiden  mutation  and 
prothrombin G20210A gene mutations were highly unlikely to be detected. Given these findings, 
the laboratory testing performed on 5/13/22 was not likely to be more beneficial for evaluation 
of the patients medical condition than any available standard therapy.