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

Summary Reviewer 2 
 
An 18-year-old male enrollee has requested reimbursement for outdoor behavioral health 
services provided from 11/03/20 through 12/31/20. The Health Insurer has denied this request 
and reported that the services at issue were investigational for the treatment of the enrollees 
medical  condition.  The  physician  reviewer  found  that  Bowen  and  colleagues  noted  that 
wilderness therapy is adventure therapy that offers a prevention, early intervention, and 
treatment modality for people with behavioral, psychological, and psychosocial issues. It can 
appeal  to  youth-at-risk  who  are  often  less  responsive  to  traditional  psychotherapeutic 
interventions. Overall, this study concluded, For participants in clinical ranges pre-program, 
there was a large, statistically significant reduction in depressive symptomology, and large to very 
large, statistically significant improvements in behavioral and emotional functioning. These 
changes were retained at the three-month follow-up. These findings indicate that wilderness 
adventure  therapy  is  as  effective  as  traditional  psychotherapy  techniques  for  clinically 
symptomatic people. In general, wilderness therapy has been considered residential level of 
care, with components of therapy frequency and intensity that qualify it as such; however, there  is a wide range of wilderness therapy programs with varying degrees of evidence-based practice 
within  each  one.  Overall,  this  patients  multiple  conditions  appear  to  have  required 
comprehensive trauma informed cognitive behavioral therapy and dialectical behavioral therapy 
modalities and significant psychiatric management. There is limited evidence available showing 
that  outdoor  behavioral  health  services  are  superior  to  these  evidence-based  treatments. 
Therefore, outdoor behavioral health services provided from 11/03/20 through 12/31/20 was 
not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested authorization and coverage for Xiaflex.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has severe erectile dysfunction and Peyronies disease.  The standard of care for treatment in this situation is insertion of penile implant with or without adjunct surgery for correction of curvature if needed intraoperatively.  Although Xiaflex has been shown to be effective in treatment of patient with Peyronies disease with intact sexual function, the value of Xiaflex in patients with Peyronies disease and coexisting severe erectile dysfunction has not been scientifically proven. Hence, Xiaflex is not medically indicated 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 51-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) performed on 3/18/19. 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 PCR testing has been compared to traditional clinical testing for vaginitis. The literature supports the use of PCR testing due to significantly higher sensitivity and negative predictive value than clinician diagnosis or in clinic testing. PCR testing has been shown to be superior for detecting more than one cause for vaginitis. PCR testing is commonly used test in clinical practice. In this case, the postoperative period is especially difficult to make an accurate diagnosis of vaginal complaints. Missing an infection could lead to a serious complication, Thus, PCR testing performed on 3/18/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 22-year-old female enrollee has requested reimbursement for mastopexy and reduction mammoplasty performed on 12/16/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees breast asymmetry. The physician reviewer found that as noted by the American Society of Plastic and Reconstructive Surgeons (ASPRS), breast deformities unrelated to cancer treatment occur in both men and women and may present either bilaterally or unilaterally. These deformities result from congenital anomalies, trauma, disease, or mal-development. Because breast deformities often result in abnormally asymmetrical breasts, surgery of the contralateral breast, as well as the affected breast, may be required to achieve asymmetry. Tuberous breast deformity is a well-defined type of congenital breast deformity and treatment for correction is considered reconstructive surgery. Breast reduction of the contralateral side and mastopexy of the affected side are recognized forms of surgical treatment for this condition. It is common in breast reconstruction to perform surgery on the contralateral side for the purpose of symmetry. The medical literature, as well as this patients clinical documentation and photographs, demonstrate the patient had a severe congenital deformity which was abnormal. Reconstructive surgery in this clinical setting was indicated to improve function and also to restore a more normal appearance. Consistent with these findings, the mastopexy and reduction mammoplasty performed on 12/16/14 were medically necessary for treatment of this patients medical condition. 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: Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for hysterectomy. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic fibroids. The physician reviewer found that there is support in the medical literature for the medical necessity of the requested procedure in this clinical setting. In this patients case, she has pain and heavy bleeding that continue to interfere with her quality of life. There are a number of surgical and non-surgical management options for symptomatic fibroids. This patient has already had a myomectomy and her symptoms are worsening. She is not a good candidate for estrogen containing medications, as she is a smoker.  In this patients case, the literature supports the hysterectomy as a treatment modality for symptomatic fibroids. Accordingly, hysterectomy is medically necessary for the treatment of this patient. Therefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement for proton beam therapy provided on 5/20/19 through 7/12/19. The Health Insurer has denied this request and reported that the services at issue were 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 services at issue. There is currently insufficient high quality clinical outcomes reported in the peer-reviewed medical literature to allow one to make definitive conclusions regarding the relative safety and efficacy of proton radiation for rectal cancer, as compared to standard of care photon-based radiotherapy. This patient could have been treated safely and effectively with photon-based radiotherapy. Therefore, proton beam therapy provided from 5/20/19 through 7/12/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 




A 67-year-old male enrollee has requested authorization and coverage for Praluent Pen injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees diabetes, dyspnea, and a positive coronary calcium score. The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved Praluent as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL cholesterol. However, this patients documented level of cholesterol is not high enough to suspect familial heterozygous hypercholesterolemia, which is diagnosed with LDL over 190. In addition, there is no evidence of clinical atherosclerotic cardiovascular disease (CAD). There are coronary calcifications on CT scan but a normal stress nuclear imaging study, showing no ischemia. Since there is no documented contraindication to treatment with Repatha, which has been authorized by the Health Insurer, the requested Praluent Pen injections are not supported as medically necessary for treatment of this patients hyperlipidemia. Based on the foregoing discussion, the requested medication 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 2

A 61-year-old female enrollee has requested authorization and coverage for endoscopic anti-reflux procedure (LINX). The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the documentation provided supports that this patient has GERD as based on pH recording when off Nexium. However, while it appears on pH testing her symptom correlation with reflux was limited, she has reportedly benefited to a significant degree from acid suppression treatment. Her record documents that symptoms worsened off proton pump inhibitor therapy. As such, she cannot be considered medically refractory to acid blocker drugs. In addition, implantation of LINX in this patients setting must be approached with caution given her documented intestinal metaplasia on esophageal biopsy. Moreover, there is a lack of medical studies in the setting of Barretts esophagus. Accordingly, the requested endoscopic anti-reflux procedure (LINX) is not likely to be more efficacious than the standard methods of treating this patients medical condition.
Based upon the information set forth above, the requested procedure 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 3

A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that the patient has a large area of abdominal wall weakness. Component separation (CS) reinforced with Strattice or porcine acellular dermal matrix (PADM) has shown favorable results for ventral hernia repair. Per a study by Richmond and colleagues, CS/PADM reinforcement should be strongly considered for the repair of significant midline ventral hernia defects.  According to another recent study by Richmond and colleagues, Biologic materials have made it such that ventral hernias can be safely repaired after bowel surgery without increased risk of complications.  Finally, a study by Huntington and colleagues note, In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and XenMatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.  The medical studies show that use of Strattice may decrease recurrence and increase the likelihood of a successful repair. This patient has documented failure with synthetic mesh. As such, the medical literature as well as this patients failure with other options support the use of Strattice in this clinical setting.  Accordingly, Strattice is likely to be a more effective treatment option than the available standard alternatives for this patient.Therefore, for the reasons stated above, the requested services are 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 58-year-old male enrollee has requested authorization and coverage for intravenous immune globulin. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees myasthenia gravis. The physician reviewer found that this patient has tried multiple therapies for myasthenia gravis, including multiple immunomodulators. He has been hospitalized due to exacerbation. These events have potential morbidity associated with them. In this case, intravenous immune globulin treatment on periodic basis helps the patient avoid hospitalization. Thus, intravenous immune globulin is likely to be more efficacious than 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: Experimental
Decision: Upheld

Summary Reviewer 3


The parent of a 14-year-old female enrollee has requested reimbursement for subtalar arthroereisis provided on 12/11/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral moderate-to-severe pes planus. The physician reviewer found that in this case, the patient presented with chronic foot and leg pain due to collapsed arches that was unresolved with conservative care. The procedure has been performed by different methods in various patient populations with reports of positive outcomes in well selected patients. Schon noted the procedure had promise, while Needleman reported 78% clinical improvement, despite high complication rates. Thus, the procedure is reserved for patients who have exhausted conservative treatments. Since this patients records demonstrate that she failed all reasonable conservative therapies prior to surgical intervention, the subtalar arthroereisis performed on 12/11/14 was likely to be more beneficial than standard available modalities. Based upon the information set forth above, I have determined 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 14-year-old male with moderately severe Crohnas disease associated with poor growth, diarrhea, nocturnal stooling, fatigue, and perianal disease with fissures and tags. The patientas parent has requested authorization and coverage for Inflectra procedure code Q5103 starting dose 7.5 mg/kg and treatment at a hospital affiliated infusion center. The Health Insurer has denied this request and reported that the requested medication and services are not medically necessary for the treatment of this patient. The physician reviewer found that adequate trough concentrations of infliximab during the induction phase are associated with better outcomes in both adults and children with Crohnas disease. Unfortunately, sub-therapeutic infliximab levels are common, leading to a need to measure drug concentrations carefully at the end of the induction period. Alternate dosing strategies have also been considered. At this time, there have not been head-to-head trials comparing standard (5 mg/kg/dose) to higher-dose infliximab induction regimen.  However, pharmacokinetic modeling studies have identified factors associated with lower trough levels. The recent study by Xiong and colleagues found predictors of sub-therapeutic infliximab exposure to include age less than 10 years, ESR greater than 30 mm/h, weight less than 30 kg, and neutrophil CD64 activity ratio greater than 6. This patient meets one of these parameters (ESR), although his neutrophil CD64 activity ratio, which is not a standard clinical measurement, is not known. European consensus guidelines state that factors indicating higher dosing are similar, including extensive disease and low serum albumin levels, which are not present in this patient.  Considering his clinical picture, higher dose infliximab induction is not indicated. The patientas provider has requested that induction doses be given in a hospital-based infusion center, and the Health Insurer has already agreed to cover the first two inductions at that location. Data on outcomes for children receiving infliximab infusions at non-hospital-based infusion centers are limited, although the practice has been described in the pediatric gastrointestinal literature. In the paper by Gupta and colleagues, over 40% of patients receiving infliximab infusions were not deemed to be appropriate candidates for non-hospital-based infusions by their medical providers. This patient does not have any obvious disqualifications for home infusion (e.g. poor vascular access). It is possible that such a characteristic will be identified during the first two infusions, in which case the question can be reconsidered. In the meantime, transition to home or independent infusion center infusions would be expected to be appropriate, for the third induction dose and maintenance dosing, assuming that the home health agency or infusion center is able to provide pediatric-trained staff. In sum, Inflectra procedure code Q5103 starting dose 7.5 mg/kg and treatment at a hospital affiliated infusion center are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 has a history of a left lower extremity deep vein thrombosis felt to be provoked in the setting of trauma, for which she was placed in an orthopedic boot, and travel. There is no family history of blood clots. Most experts recommend testing for all five inherited thrombophilias (protein S, C, and antithrombin deficiencies, factor V Leiden and prothrombin gene mutation) and antiphospholipid syndrome in those who are younger than 45 years of age. In an analysis by Weingarz and colleagues of unselected patients with venous thromboembolic event and a median age of 43 years, at least one thrombophilic disorder was identified in half of the cohort. This patient is young and had a venous thromboembolic event, and although provoked, meets criteria for more intense testing. Therefore, laboratory testing performed on 6/26/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for acute inpatient psychiatric treatment from 11/18/16 through 12/4/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions The physician reviewer found that there is a lack of support for the medical necessity of the services at issue in this clinical setting. On 11/17/16, although the patient continued to endorse depression and anxiety, her suicidal ideation was passive in nature and there was no intent.  She denied homicidal ideation.  She was no longer a danger to herself, and she was not a danger to others.  She was cognitively intact.  She was able to care for herself and adequately perform activities of daily living.  She was not gravely disabled.  Beyond that date, she continued to report depression, anxiety, poor sleep, somatic preoccupation, and preoccupation with family finances. These states appear to be her baseline.  The record notes that her medication changes were tolerated well and were not of a complicated nature that required inpatient level of care.  She was participating in therapies and groups offered. It should be noted that dialectic behavior therapy is typically an outpatient modality. The issues this patient was working on, emotional regulation, improvement of mood, decrease feelings of being overwhelmed, increase structure, identification of triggers of suicidal thoughts, and building coping skills, could have continued in PHP. Based on the documentation, this patient could have been stepped down on 11/18/16. As such, inpatient psychiatric services from 11/18/16 through 12/4/16 were not medically necessary. Therefore, for the reasons stated above 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 3

A 54-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 2/5/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines do not support the DecisionDx testing for use outside of the clinical trial setting. Moreover, there is a lack of peer-reviewed medical literature demonstrating that the results of the DecisionDx testing would change the recommended therapy or long-term outcomes. Consequently, the DecisionDx melanoma assay provided on 2/5/16 was not 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 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 63-year-old female who has requested reimbursement for harvest auto stem cells provided on 1/28/19 and 1/29/19. She has a history of multiple myeloma. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Autologous stem cell transplantation is considered a standard of care in the treatment of multiple myeloma with a good response after primary therapy. This approach is supported by the National Comprehensive Cancer Network (NCCN) guidelines. Stem cell collection from the patient after stimulation of the bone marrow to produce increased stem cells is also standard. Therefore, harvest auto stem cells provided on 1/28/19 and 1/29/19 were medically necessary for the treatment of this patient.