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

Summary Reviewer 


A 37-year-old female enrollee has requested reimbursement for Butrans received on 10/3/15. The Health Insurer has denied this request indicating that the medication at issue was medically necessary for treatment of the enrollees medical condition. The physician reviewer found the patient presented with a history of chronic pain. The step wise WHO ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. (Raffa et al). In this patients case it does not appear all non-opioid treatment options had been utilized. Further, there was no plan in place to monitor this patients medications either historically and currently (Jamison et al). Moreover, it is unclear as to whether the diagnosis of chronic regional pain syndrome (CRPS) was supported. Based upon the information provided, the patient only appears to have met one of the criteria for such diagnosis and as noted in the medical records the patient has chronic pain syndrome and possibly fibromyalgia (Wurtman). Finally, multiple minimal requirements for opioid prescribing were not documented and the need to use Butrans to taper the patients opioid use is not supported. Pain specialists generally use taper medications that are not long-acting. Rather than using Butrans, buprenorphine oral form or methadone would be used for tapering purposes to get off another opioid. Moreover, there is no need to actually change opioids to taper; the physician can simply start decreasing the already prescribed opioids. As such, the medical necessity of the Butrans obtained on 10/3/15 has not been established. For the reasons set forth above, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 64-year-old female has requested reimbursement for DecisionDx-Melanoma assay provided on 3/21/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of the services at issue were not likely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma assay provided on 3/21/18 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 41-year-old male with a history of chronic left knee pain and swelling on both the medial and lateral aspects.  The patient has requested reimbursement for synovectomy performed on 6/19/20 (CPT 29876). The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found the article by Goyal and colleagues pertains to chronic synovitis involving a single large joint. In this study, 61 patients with chronic mono-articular synovitis of the knee were followed for two years and underwent x-rays, MRI scans, and arthroscopic synovectomy with histopathological examination. The histopathological examination showed chronic nonspecific inflammation in 28 patients (46%). Felson and colleagues discussed the relationship of untreated chronic synovitis to osteoarthritis, indicating the medical necessity of such treatment. In this patients case, the synovectomy was medically necessary for establishing a diagnosis as well as symptomatic relief by resecting hypertrophic synovium. The patient presented with chronic pain and swelling of one knee for a year. There was a loose body on the MRI that turned out to be hypertrophied synovium with calcification. The joint effusion and restricted range of motion (0-90) was associated with chronic synovitis that warranted arthroscopic synovectomy for a definitive diagnosis as well as treatment. The diagnosis was chronic non-specific synovitis, which was treated appropriately. Therefore, synovectomy performed on 6/19/20 (CPT 29876) was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 54-year-old female has requested reimbursement for chemotherapy treatment provided from 10/06/17 through 12/13/17. The Health Insurer has denied this request indicating that the medication regimen at issue was considered investigational for treatment of the enrollees gallbladder cancer. The physician reviewer found that although there is no standard second-line therapy for patients, most experts would recommend a fluorouracil based regimen after progression on gemcitabine and oxaliplatin. There are phase II trials that support the following combinations: gemcitabine/oxaliplatin, gemcitabine/capecitabine, capecitabine/cisplatin, capecitabine/oxaliplatin, 5-fluorouracil/oxaliplatin, 5-fluorouracil/cisplatin, and the single agents gemcitabine, capecitabine, and 5-fluorouracil in the unresectable or metastatic setting. There is a lack of literature to support the combination of FOLFIRI plus bevacizumab (Avastin) for second-line metastatic gallbladder cancer. In sum, chemotherapy treatment provided from 10/06/17 through 12/13/17 was not likely to have been more effective than other methods of treating this patient. Based upon the information set forth above, the medication regimen 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 53-year-old male enrollee has requested reimbursement for the bronchial thermoplasty provided from 1/21/15 through 4/8/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees persistent asthma.  The physician reviewer found that bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees Centigrade. There are three bronchoscopic procedures. The first procedure treats the right lower lobe, the second focused on the left lower lobe, and the third procedure is for both upper lobes. The procedures are scheduled three weeks apart. The provider states that bronchial thermoplasty has been U.S. Food and Drug Administration (FDA) approved for the treatment of patients with asthma. However, bronchial thermoplasty has not been FDA approved for use in this clinical setting. Further, there is a paucity of data from well designed, randomized, controlled clinical trials demonstrating the long-term safety and efficacy of the device for use as a generally accepted, standard of care for the treatment of asthma. The provider states the patient has a progressive decrease in the quality of life but there is no documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. For these reasons, the bronchial thermoplasty services provided from 1/21/15 through 4/8/15 were 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 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 


A 54-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Perjeta and Herceptin combination from 9/08/15 forward.  The Health Insurer has denied this request indicating that the medications at issue were not and are not medically indicated for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication combination.  Perjeta is a monoclonal antibody which targets the HER2 positive breast cancer cells, similar to, but not exactly in the same way, as Herceptin.  In metastatic breast cancer, when used in combination with Herceptin and Taxotere, Perjeta yields superior progression-free survival compared to treatment with Taxotere and Herceptin without Perjeta.  Combining Perjeta with Herceptin and chemotherapy also appears superior in the neoadjuvant setting.  However, there is a lack of data supporting the use of combined Herceptin and Perjeta in the adjuvant setting.  At this time, the current medical evidence has not established the medical necessity of the requested medication combination in this clinical setting.  All told, Perjeta and Herceptin combination from 9/08/15 forward were not and are not medically indicated for the treatment of this patient.  Therefore, the medications at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 71-year-old male enrollee has requested reimbursement ablation of the prostate, transrectal high intensity focused ultrasound (HIFU) including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who has a history of prostate cancer. The physician reviewer found that the patient is a 71-year-old male who was found to have elevated prostate specific antigen (PSA) in 2011. The patient underwent transrectal ultrasound and guided biopsy of his prostate at that time. He was found to have moderate risk prostate cancer with clinical stage T2c. He was consulted regarding treatment options. The patient elected high intensity focused ultrasound ablation of his prostate (HIFU) in 2011. Initially he did well; however, he had progressive elevation of his PSA. It was assumed that the patient had a recurrence. He again underwent ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17. The patient has requested reimbursement for the services at issue. The Health Insurer has denied this request for reimbursement and noted that the ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17 was investigational for the treatment of this patients medical condition.High-intensity focused ultrasound therapy for prostate cancer is a relatively new procedure. The U.S. Food and Drug administration has approved this procedure to be safe for treatment of prostate ablation. However, there is no specific indication for treatment for prostate cancer and there is no significant information regarding salvage therapy following HIFU. At this time, HIFU therapy for recurrent prostate cancer following initial treatment is not considered a standard of care in this clinical setting. Accordingly, transrectal HIFU including imaging guidance performed on 12/20/17 was not likely to have been more effective when compared to other treatment modalities for the treatment of this patients medical condition. 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 parent of a 17-year-old male enrollee has requested reimbursement for mental health residential treatment services provided from 4/9/14 through 10/19/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse and parent-child relational problem. The physician reviewer found that the additional data confirms the history of antisocial behavior and running away. However, there is a lack of evidence that placement in this facility addressed the patients issues of poor motivation. The additional records did not document any further indication of risk to self or others, significant medical comorbidity, risk of withdrawal or other symptoms which required containment on a 24-hour basis. As noted in the previous review, the American Psychiatric Association (APA) practice guidelines indicate that patients should be managed in the least restrictive setting which is likely to be safe and effective. The additional records do not include any indication that the patient could not have been safely managed on an ambulatory basis during the time period in question and the records from the facility fail to indicate that the patient could not have been effectively managed on an outpatient basis. Further, the records provide no evidence of withdrawal symptoms and no clinical evidence that treatment at a lower level of care was not feasible, available or appropriate for the patients condition, as recommended in the Milliman Care Guidelines. Overall, the records do not support the medical necessity of mental health residential treatment services from 4/9/14 through 10/19/14 as treatment for this patients medical condition. Accordingly, 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 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that there is sufficient support for the Afirma gene test performed on 7/5/16 in this clinical setting. This patients biopsy was suspicious for follicular lesion of undetermined significance. The Afirma testing was suspicious, and a determining factor in delineating the further course of action to assess whether a surgical procedure was warranted. Afirma testing is considered standard protocol on fine needle aspirations performed on thyroid nodules. In sum, 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 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 2


A 50-year-old male has requested reimbursement for Anser IFX testing performed on 4/15/15.  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 the current medical evidence has not established the superior efficacy of the services at issue.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well-controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not 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. As such, Anser IFX testing performed on 4/15/16 was not likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a one-year-old male enrollee has requested authorization and coverage for Olumiant
1 mg tablet. The Health Insurer has denied this request and reported that the requested medication
is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that AGS is a rare monogenic interferonopathy characterized by variable neurologic dysfunction,
ranging from mild spastic paraparesis to quadriparesis and severe cognitive disability. Mutations
on one of six genes involved in nucleic acid repair have been implicated in the majority of cases,
with additional rare ade novoa autosomal dominant cases. Excessive interferon production results
in systemic inflammation and extensive end organ injury. Patients typically present with altered
mental status, including lethargy and irritability, feeding intolerance, and neurologic
abnormalities, such as loss of gross motor skills, seizures, or spasticity. Some patients may also
exhibit signs of systemic autoinflammation, such as fevers and skin involvement. There is evidence
of basal ganglia calcification, chronic cerebrospinal fluid (CSF) lymphocytosis, and elevated CSF
interferon type I. There are similarities and symptom overlap with systemic lupus erythematosus.
Overall, there is currently significant morbidity and high rate of mortality associated with this
syndrome. As a disorder of inappropriate immune activation, AGS has prompted interest in
immune-mediation therapies, including Janus kinase (JAK) inhibitors, reverse transcriptase
inhibitors, anti-IFN-alpha antibodies, anti-interleukin antibodies, antimalarial drugs, and other
cGAS inhibitors. Olumiant (baricitinib) is an oral JAK1/2 inhibitor that has been approved for
treatment of rheumatoid arthritis and has been used in case studies on patients with AGS.
Individual patients with AGS experienced decreased skin manifestations as well as improved
neurologic function following treatment with baricitinib.
This medication has not been approved by the U.S. Food and Drug Administration (FDA) in this
population, and the majority of articles cite the need for ongoing clinical studies, which are
particularly challenging given the heterogeneous nature of this disease. However, the FDA has
listed AGS as one of the conditions for which baricitinib can be used on a compassionate basis.
This medication is the only treatment available and is more likely to be beneficial than standard
therapy (symptomatic treatment only). Therefore, Olumiant 1 mg tablet is likely to be more
beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 69-year-old female enrollee has requested reimbursement for air ambulance services provided on 6/18/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Shirley Ryan Ability Lab is a state of the art inpatient rehabilitation campus determined to be the best option for this patient. On 6/15/18, a request for urgent pre-authorization for medically configured fixed-wing air transport was sent to the Health Insurer. On 6/18/18, the patient was transferred by medically configured fixed-wing aircraft to the receiving inpatient rehabilitation center. On 6/19/18, four days after the request for urgent pre-authorization, the Health Insurer authored a denial letter for the services in question. As detailed in the air ambulance records, the patient at the time of transport was described as alert but nonverbal, and she did not follow commands. The records noted left-sided weakness. She was not a candidate for commercial air travel. The receiving facility was greater than 303 miles away with a reported five-hour ground transport time; well outside generally accepted time limits for this type of patient. In sum, the Shirley Ryan Ability Lab was determined to be the best option for this patient, and she was not a candidate for ground transport or commercial air travel. Therefore, air ambulance services provided on 6/18/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 45-year-old female with chronic low back pain, hip/buttock and tailbone pain and numbness and tingling above the knee. The onset of pain was atraumatic and began in November 2013. On 6/07/18, her pain was rated at 7 to 9/10 and was getting worse. She is status post L3-4 lumbar fusion and right sacroiliac arthrodesis. The patient has requested coverage for left sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The available medical literature states that sacroiliac fusion may be recommended on a case-by-case basis as a last line of therapy (including either open or minimally invasive procedures) as treatment for sacroiliac joint infection, tumor involving the sacrum, disabling pain due to sacroiliitis due to spondyloarthropathy, or sacroiliac pain due to severe traumatic injury. The procedure may be required for multisegmental spinal constructs (i.e., scoliosis or kyphosis surgery). However, it is not recommended for mechanical low back pain, non-specific low back pain, sacroiliac joint disruption (in the absence of major pelvic fracture), degenerative sacroiliitis, or sacroiliac joint osteoarthritis. In this case, the submitted records do not indicate the patient has been diagnosed with the conditions which have quality evidence to support benefit from sacroiliac fusion. Thus, the superior efficacy of left sacroiliac joint fusion has not been established. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.