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

Summary Reviewer  
The patient is a 38-year-old transgender male. In a letter dated 8/23/22, the provider reported that 
the patient had a diagnosis of gender dysphoria and recommended masculinizing body contouring 
procedures. The patient has requested authorization and coverage for 15839-22 excision, excessive 
skin and subcutaneous tissue (includes lipectomy), other area, and 15877 x 12 suction assisted 
lipectomy, trunk. The Health Insurer has denied this request and reported that the requested service 
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 services. The World Professional Association for Transgender 
Health (WPATH) notes that medically necessary gender-affirming include but are not limited to 
hysterectomy  with  or  without  bilateral  salpingo-oophorectomy;  bilateral  mastectomy,  chest 
reconstruction or feminizing mammoplasty, nipple resizing or placement of breast prostheses; 
genital reconstruction, for example, phalloplasty and metoidioplasty, scrotoplasty, and penile and 
testicular prostheses, penectomy, orchiectomy, vaginoplasty, and vulvoplasty; hair removal from 
the face, body, and genital areas for gender affirmation or as part of a preoperative preparation 
process; and gender-affirming facial surgery and body contouring. The WPATH further notes that 
non-genital procedures are routinely performed for the treatment of gender dysphoria and that 
these surgical interventions are often of greater practical significance in the patients life than 
reconstruction of the genitals. Given that current medical literature supports the use of body 
contouring, lipectomy, and skin removal as treatments for gender dysphoria, the requested services 
are medically indicated. Therefore, 15839-22 excision, excessive skin and subcutaneous tissue 
(includes lipectomy), other area, and 15877 x 12 suction assisted lipectomy, trunk are medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 4/29/15. 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 there is a lack of support for the services at issue in this clinical setting.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  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 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 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.  Thus, the superior efficacy of Prometheus Anser IFX testing performed on 4/29/15 has not been established.  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 parent of a four-year-old male enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy services provided on 11/19/16 through 12/21/16, and forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees feeding and eating difficulties. The physician reviewer found that as noted by Manikam and Perman, the consequences of feeding disorders can be severe and treatment can include treatment of the medical condition, behavioral modification to alter the childs inappropriate learned feeding patterns, and parent education and training in appropriate parenting and feeding skills. This patient has made progress and continues to make progress with his current occupational therapy services. The patient should be able to continue occupational therapy until he has made further progress and the provider finds that he is at his maximum potential. Accordingly, the occupational therapy services provided on 11/19/16 through 12/7/16, and forward were and are medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 50-year-old male enrollee has requested reimbursement for Decision-Dx Melanoma testing performed on 11/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the National Comprehensive Cancer Network guidelines state that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to help differentiate benign from malignant neoplasms, or to help distinguish melanomas at low-risk versus high-risk for metastasis, routine genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. This patient has an early stage melanoma. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing provided on 11/14/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 68-year-old female enrollee has requested reimbursement for DecisionDX Melanoma Assay provided on 2/05/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees malignant melanoma. The physician reviewer found that the staging and prognosis of cutaneous malignant melanoma is classically determined by the system spelled out by Balch.  There may be some further value in adding the mitotic rate to this system.  As per this system, this patient would have been staged as a T1a melanoma, with an expected 10-year survival of at least 88%.  There is no information in the records submitted as to whether she had sentinel node done, nor any clinical follow-up since her diagnosis in 2011.  It is also not clear why this assay was ordered in February 2016 when her initial diagnosis was in 2011.  DecisionDX Melanoma Assay is a study of 31 genes in melanoma cells.  It then classifies that particular melanoma as either class 1 (with a 97% disease-free rate at five years) or class 2 (with a 31% disease free-rate at five years).  It is not as yet clear how DecisionDX data compares to the ten-year data of the Balch determinations, and whether it can be used to make clinical practice decisions.  This is particularly in question in this patients case given her pathologic findings and excellent prognosis.  All told, DecisionDX Melanoma Assay provided on 2/05/16 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 28-year-old female with a medical history including fibromyalgia, migraines and 
chronic fatigue. She is requesting naltrexone HCl for the treatment of fibromyalgia and migraine 
pain. The physician reviewer found that Fibromyalgia is a chronic pain disorder with treatment 
directed at reducing the major symptoms including pain, fatigue, insomnia and cognitive 
dysfunction. Treatment is approached in a stepwise pattern, starting with education and 
treatment of any mood or sleep disturbances. Initiation of low-dose tricyclic antidepressants or 
selected antidepressants or anticonvulsants are tried when individuals do not respond to 
education alone. Key aspects of treatment include an exercise program, physical therapy, 
psychological interventions and multidisciplinary programs.  Combination therapy is also 
recommended. During flares of pain, acetaminophen, tramadol and nonsteroidal anti-
inflammatory drugs are recommended. There is limited data to support the use of naltrexone in 
the treatment of fibromyalgia. Low-dose naltrexone has been associated with improved general 
satisfaction with life and with improved mood but not associated with improved fatigue or 
sleep. In this case, the documentation does not support that the patient has tried and failed all 
recommended treatment for fibromyalgia with associated chronic fatigue. There is limited data 
to support the use of low-dose naltrexone for the treatment of fibromyalgia. The data that is 
available does not show an improvement in chronic fatigue, which is one of the patients 
prominent symptoms. Therefore, naltrexone HCL 50 mg used to compound to the final 
outcome strength of 4.5 mg provided from 6/07/21 to October 2021 was not medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewer found that the medical evidence has not established the superior efficacy of services at issue.  Most of the studies on the use of platelet-rich plasma therapy for plantar fasciitis advise of some efficacy.  However, the reviewers often note that further investigation is necessary to fully understand this treatment and its full potential.  There is a lack of large, double blind, placebo-controlled studies for this treatment modality.  Currently, the minimally invasive endoscopic plantar fasciotomy demonstrates a 90% cure rate.  Physical therapy including ultrasound, stretching of plantar fascia, off-loading of pressure to the plantar fascia with casting, local steroid injections to the origin of the plantar fascia, and orthotics all demonstrate a high cure rate for plantar fasciitis.  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 57-year-old female enrollee has requested authorization and coverage for duloxetine 60 mg, #60 per 30 days. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees fibromyalgia.   The physician reviewer found that a review of the literature reveals that there is a lack of evidence that doses greater than 60 mg per day of duloxetine confer additional benefit for fibromyalgia patients, even in patients who do not respond to a 60 mg dose. In addition, higher duloxetine doses are associated with a higher rate of adverse reactions. Further, the documentation does not reveal that the patients history, symptoms, and examination findings are consistent with a diagnosis of fibromyalgia. Moreover, the documentation does not reveal that the patient has had significant objective functional improvement or a significant objective improvement in pain on duloxetine. For these reasons the documentation does not support the medical necessity of duloxetine 60 mg, #60 per 30 days for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication quantity is 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 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the records indicate that this patient has ulcerative colitis that has remained severe despite treatment with azathioprine and Humira. An Anser ADA test was performed to help determine the patients course of treatment. Determining a patients Humira levels has become important when a patient loses response to Humira, which may require increasing the dose. In this case, there is concern as the disease is advanced and the patient had already failed several regimens. Determining whether the patient has therapeutic levels and antibodies may point the treating provider toward a different drug or another etiology. Moreover, it has been shown that checking for these antibodies helps optimize clinical response by helping achieve a more optimal drug concentration (Baert, et al; Vande Casteele, et al). 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for mental health residential treatment from 5/13/15 through 6/07/15. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees alcohol use disorder. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders.  He alcohol use dominated her daily routine and generated distress.  Further, her drinking negatively impacted her health, strained meaningful relationships, and caused significant impairment across multiple domains of functionality.  Additionally, her motivation and social supports were limited.  In this patients case, the residential treatment provided was safe, appropriate and consistent with good practice.  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.  Further, the duration of the disputed treatment course was within community practice standards.  All told, mental health residential treatment provided from 5/13/15 through 6/07/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 46-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The records note a history of hyperlipidemia, intolerance to statin medications and Zetia, but no documented cardiovascular disease. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied only in patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit either of those categories. There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dL, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or younger than 55 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism. PCSK9 inhibitors have not been studied in other patient populations, such as this patient. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 


An 18-year-old male enrollee has requested reimbursement for residential treatment services from 8/04/15 through 12/10/15.  The Health Insurer has denied this request indicating that the not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based upon the records, this patient was able to engage in therapy.  The patient was able to confront various issues with his family and had the ability to express emotion with less depression.  The patient did not appear to be a safety risk according to the records and was not showing any impairment of reality, including command hallucinations, agitation or aggression or withdrawal.  The medical evidence does not support continued treatment at the residential treatment facility in this clinical setting.  Per the records, the patient could have been safely and effectively treated in a less restrictive setting.  In sum, residential treatment services from 8/04/15 through 12/10/15 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). 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 U.S. Food and Drug Administration has approved the LINX device for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. This patient has gastroesophageal reflux as based on pH recording. However, it appears he has benefited substantially from pantoprazole, and symptoms of gastroesophageal reflux disease recur when he discontinues this drug. As such, he cannot be considered refractory to medical management. Given this patients excellent response and tolerance to conventional acid suppression medication and the attendant surgical risks of LINX implantation, the requested CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing 
performed on 2/04/21. The Health Insurer has denied this request and reported that the 
services at issue were investigational for the evaluation of the enrollees medical condition. The 
physician reviewer found that this patient had lymphadenopathy that was suspicious for breast 
cancer recurrence. The priority should have been resection or biopsy of the lymph node 
followed by mutation analysis. Instead, the patient had a peripheral blood analysis of oncogenic 
mutations. Guardant360 testing cannot be used to diagnose metastatic disease. The 
Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70 
genes. Von Hoff and colleagues performed a clinical study directly compared the use of 
targeted agents with conventional chemotherapy approaches. The study involved 86 patients, 
and the progression-free survival on regimen selected by molecular profiling was compared to 
the progression-free survival on the last chemotherapy regimen. The regimen selected by 
molecular profiling offered a 27% survival advantage. This trial has very significant results for 
patients with stage IV tumors. Under normal circumstances with the diagnosis of metastatic 
disease, a comprehensive mutational analysis is indicated to better hone therapeutic options. 
However, in this case, the test was being used for diagnostic purposes, to diagnose the 
presence of stage four disease. There is a lack of support for the services at issue in this setting. 
Therefore, Guardant360 testing performed on 2/04/21 was not likely to have been more 
beneficial than any available standard therapy.