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

Summary Reviewer 

The patient is a 51-year-old female who underwent a colonoscopy on 5/10/19 for the indication of colorectal cancer screening. Per the records, this revealed two polyps (which were removed) and internal hemorrhoids. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. According to the American Society of Anesthesiologists guidelines 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 is more likely 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, American Society of Anesthesiologists (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. 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. All told, monitored anesthesia care provided on 5/10/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 52-year-old female enrollee has requested authorization and coverage for endovenous ablation.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees varicose veins. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  Per the submitted documentation, the patient has symptoms which are impacting her activities of daily living.  In a letter dated 4/12/16, the provider noted bilateral leg pain, swelling, numbness, throbbing, and aching when standing.  The current medical evidence supports the requested services for the treatment of this patient.  All told, the requested endovenous ablation is medically indicated in this patients case.  Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 35-year-old female who is pregnant. The patient has requested authorization and coverage for Makena injection (hydroxyprogesterone caproate 10 mg). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the literature supports the use of progesterone treatment to decrease the risk of preterm delivery in a patient who has a history of preterm birth. Research has shown that a prior spontaneous preterm birth is a risk factor for a subsequent spontaneous preterm birth, whether the initial preterm delivery was a singleton or a twin pregnancy. Although no study has specifically evaluated whether progesterone supplementation decreases the risk of a preterm birth of a singleton after a previous spontaneous preterm birth of twins, it is appropriate for providers to recommend this therapy. There is a theoretical benefit given available data. This provider is practicing within current standard of care, and progesterone therapy is appropriate in this clinical setting. Therefore, Makena injection (hydroxyprogesterone caproate 10 mg) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 61-year-old enrollee has requested authorization and coverage for clobetasol ointment. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. This patient has been diagnosed with lichen sclerosus et atrophicus involving the genital skin. Lichen sclerosus et atrophicus is a chronic inflammatory condition. If left untreated, this can lead to squamous cell carcinoma. Treatment with ultrapotent topical steroids is recommended to reduce inflammation. Clobetasol ointment is an ultrapotent topical steroid commonly used for the treatment of lichen sclerosus et atrophicus. Therefore, clobetasol ointment is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 61-year-old female has requested reimbursement for code 73721, magnetic resonance imaging (MRI) lower extremity, any joint, without contrast, performed on 6/12/19. 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 the submitted documentation supports the services at issue in this clinical setting. An MRI was performed on 6/12/19 and showed medial collateral ligament (MCL) and anterior cruciate ligament (ACL) disruption consistent with internal derangement. This patient had clinical findings of knee instability, per the history given to the radiologist. Per the current guidelines, knee instability, decreased range of motion and joint effusion are valid indications for MRI without antecedent six weeks of conservative therapy. There is sufficient support for the services at issue in this clinical setting. Therefore, MRI lower extremity, any joint, without contrast performed on 6/12/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 16-year-old male enrollee has requested authorization and coverage for mastectomy. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that while most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive. Although it may be much easier to see a phalloplasty or a vaginoplasty as an intervention to end lifelong suffering, for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. This patient has well documented gender dysphoria including a letter of support for surgery from his mental health professional and his pediatric endocrinologist who are part of a qualified multidisciplinary team. He currently meets the WPATH SOC criteria as well as the Endocrine Society guideline criteria for breast surgery. The patients parents, medical providers, mental health provider, and surgical providers are supportive. Thus, the requested mastectomy is medically necessary to align his body with his gender identity and help alleviate the distress associated with gender dysphoria. Based on the foregoing discussion, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for Monovisc knee injections provided on 5/18/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees knee osteoarthritis. The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis. In addition, the benefits of hyaluronic acid are long-lasting as compared with intraarticular corticosteroids. In a systematic review of meta-analyses, Campbell and colleagues compared hyaluronic acid injections with other non-operative treatment modalities for knee osteoarthritis. The authors found that intraarticular hyaluronic acid improves knee pain and function for up to 26 weeks. Moreover, Maheu and colleagues noted that the benefits of intraarticular hyaluronic acid on knee osteoarthritis may include mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) andthe re-establishment of joint homeostasis through induction of endogenous HA [hyaluronic acid] production, which continues long after the exogenous injection has left the joint. This patient has reported excellent results with prior hyaluronic acid injections. All told, the Monovisc knee injections provided on 5/18/18 were medically necessary for treatment of this patients bilateral knee osteoarthritis. Based on the foregoing discussion, 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 36-year-old male enrollee has requested reimbursement for air ambulance transport provided on 2/12/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to establish the medical necessity of the services at issue. Based on the medical records submitted for review, there is no medical reason for the patients transfer. The patient was receiving adequate care at the initial location in California. The promise of successful weaning off mechanical ventilation does not warrant the risks for transferring a patient such a long distance. In some case, patients are better off on the ventilator. In this case, there is no evidence that this patient, who has been on a ventilator since 2011 was weanable. All told, the air ambulance transport provided on 2/12/14 was 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 19-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 8/1/13 through 9/26/13. 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 that the mental health residential treatment provided from 8/1/13 through 9/26/13 were medically necessary for treatment of the patients medical condition. The documentation submitted for review supports the residential placement. The patient presents with multiple diagnoses including depressive disorder, autism spectrum disorder, attention-deficit/hyperactivity disorder and substance abuse. According to Mayes and colleagues Comorbid psychological problems most highly predictive of ideation or attempts were depression, behavior problems, and teased. Almost half of children with these problems had suicide ideation or attempts. The patient had recently been hospitalized due to an overdose of Xanax. The treatment at issue was medically necessary to assist the patient with handling life stressors in the context of autism spectrum disorder. Thus, the residential mental health 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


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  There is a lack of support for breast tomosynthesis in patients case.  Generally, bilateral breast tenderness is an unlikely presenting symptom for breast cancer.  In addition, she did not have particularly dense breasts, and her mammogram was unchanged when compared to a prior mammogram.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms.  Thus, breast tomosynthesis performed on 5/23/16 was not likely to have been of greater benefit than other available modalities.  Based upon the information set forth above, the service at issue was 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 


A 40-year-old female enrollee has requested authorization and coverage for spinal fusion.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has been diagnosed with lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1. The physician reviewer found there is sufficient support for the requested services in this patients case.  Evidence-based medical guidelines support lumbar fusion in the setting of degenerative spondylolisthesis with symptomatic radiculopathy or spinal stenosis when nonoperative treatment has failed.  Lumbar fusion is also supported in the setting of wide decompression with anticipated intraoperative instability.  This patient presents with persistent worsening low back pain radiating into the left lower extremity to the calf consistent with a left L5 radiculopathy.  Significant functional difficulty is documented in ambulation and activities of daily living.  Detailed evidence of a comprehensive nonoperative treatment protocol trial and failure has been submitted.  Clinical examination findings were consistent with imaging evidence of lateral recess stenosis at L4-5 and severe foraminal stenosis at L5-S1.  There is radiographic evidence of spondylolisthesis at L4-5 exaggerated in extension and reduced in flexion.  The treating provider has planned complete facetectomy and foraminotomy to achieve adequate nerve root decompression which would result in temporary intraoperative instability and necessitate fusion. Thus, the requested spinal fusion is medically indicated 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for monitored anesthesia care (MAC) services provided on 2/12/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer. The physician reviewer found that The American Society of Anesthesiologist (ASA) noted that MAC with sedation may be necessary to improve patient cooperation, decreased movement, and reduce discomfort during endoscopy procedures in patients with significant psychiatric disorders, cognitive dysfunction and movement disorders. The ASA also noted that MAC is necessary for patients in situations of extreme procedure anxiety. The records indicate that this patient has a history of extreme anxiety and panic attacks. Thus, the MAC services were appropriate and medically necessary during the colonoscopy performed on 2/12/15 for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3  The parent of a 16-year-old male insured has requested reimbursement for a laboratory test 
performed on 2/10/23. The Health Insurer has denied this request indicating that the services at 
issue were considered investigational for the evaluation of the insureds Chrons disease. 
The physician reviewer found that according to Cheifetz and colleagues, When infliximab de-
escalation (dose reduction) is considered in patients in remission, proactive TDM both before and 
after de-escalation should be performed. In this case, the patients Inflectra dosage was reduced. 
Evaluating Inflectra drug levels and antibody levels both before and after changing dose is the 
standard of care for this patient. For this reason, the laboratory test performed on 2/10/23 was 
likely to have been more beneficial for the evaluation of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 20-year-old female enrollee has requested authorization and coverage for arthroscopy of the knee. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of knee pain. The physician reviewer found that the peer reviewed literature supports arthroscopy debridement of cyclops lesions, lysis of adhesions and manipulation under anesthesia of the knee to restore full knee extension when loss of full extension and painful stiffness persist, despite aggressive rehabilitation following anterior cruciate ligament reconstruction. This patient presents with persistent right knee pain and stiffness nearly three years status post anterior cruciate ligament reconstruction for complete rupture. The submitted documentation supports the patients loss of full extension. There is documented pain consistent with imaging evidence of synovitis, intercondylar notch scar tissue, and possible cyclops lesion. Evidence of long-term reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. As such, the requested services are medically necessary for treatment of this patients medical condition.  Therefore, based on the reasons stated above, 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 1

The patient is a 61-year-old male with benign prostatic hyperplasia (BPH) and American Urological Association (AUA) symptom score of 20. The patient underwent UroLift on 10/18/16 to relieve obstructive symptoms. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational.  Currently, there is a lack of peer-reviewed medical literature or clinical guidelines that support the utility of UroLift with standard available treatment options. As noted by Chung and Woo, UroLift appears to be a well tolerated and effective minimally invasive treatment for lower urinary tract symptoms due to BPH in men who wish to preserve sexual function or who are not suitable for invasive surgery. Further studies will confirm the currently mixed results regarding intraprostatic botulinum toxin or ethanol injections. Thus, additional investigation is appropriate to confirm these initial results. For these reasons, the UroLift procedure provided on 10/18/16 was 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 service 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: Upheld

Summary Reviewer 3


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 Anser IFX test was ordered to direct the use of Remicade in this patient with Crohns disease. However, the use of Anser IFX to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Based on the clinical literature, the Anser IFX testing performed on 4/15/15 was not likely to be more beneficial for treatment of the patients medical condition than standard management.  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

A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found there is sufficient support for the services at issue in this patients case.  According to the American Society of Colon and Rectal Surgeons guideline for the treatment of fecal incontinence, sacral neuromodulation may be considered as a first-line surgical option for incontinent patients with and without sphincter defects.  The treatment consistently demonstrates reduction in frequency of incontinence episodes in studies.  In this patients case, the permanent sacral nerve stimulator provided on 12/09/14 was likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.