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

Summary Reviewer 3

A 33-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation (64568 and 0466T). 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 medical evidence supports the requested services in this patients case. The records document an apnea-hypopnea index of 22.3. The patient has been unable to tolerate continuous positive airway pressure. Clinical studies of the use of hypoglossal nerve stimulation indicate that patients benefit from this device when they have a body mass index (BMI) less than 32. This patient has a BMI of 21.3. Per the medical evidence, selective upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment. Woodson and colleagues noted long-term improvements and demonstrated that adverse events were uncommon. Thus, the requested hypoglossal nerve stimulation (64568 and 0466T) is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 66-year-old male who presented with lower urinary tract symptoms. The 
patient has requested reimbursement for MRI of pelvis performed on 11/08/21. The physician 
reviewer found that the submitted documentation fails to demonstrate the medical necessity 
of the services at issue. This case was previously reviewed, and the patient submitted additional 
documentation for reconsideration. According to the American Urological Association Standard 
Operating Procedure referenced below, there is level 1 data to support the recommendation of 
multiparametric MRI prior to biopsy for all men without a previous history of biopsy who are 
under consideration for prostate biopsy. Per the AUA, Multiparametric MRI-targeted prostate 
biopsy in men at suspicion of prostate cancer, with no previous history of prostate cancer, 
detects more clinically significant prostate cancer when combined with systematic biopsy, and 
less clinically insignificant prostate cancer, than systematic biopsy alone. However, in this case, 
the patient had an elevated PSA level in the setting of a urinary tract infection. This had 
normalized after antibiotic treatment. Additionally, digit rectal examination was normal. There 
was no suspicion about prostate cancer. Performing an MRI would not be considered a clinically 
appropriate and generally accepted standard for management of this patients medical 
condition. There are indications for performing MRIs based on the risk of prostate cancer. If a 
patient has an elevated PSA and/or abnormal digital rectal examination, an MRI may be 
indicated. As noted above, this patients PSA had normalized to 3.69 by 10/20/21, and his 
digital rectal examination was normal. The additional documentation provided for 
reconsideration did not alter the original determination. Therefore, MRI of pelvis performed on 
11/08/21 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found, while cell-free fetal DNA testing is a very effective screening test for women at high risk for fetal trisomy, the use of this test for lower risk women has not been established.  The American Congress of Obstetricians and Gynecologists (ACOG) currently states Given the performance of conventional screening methods, the limitations of cell-free DNA screening performance, and the limited data on cost-effectiveness in the low-risk obstetric population, conventional screening methods remain the most appropriate choice for first-line screening for most women in the general obstetric population. Since this patients risk of Down syndrome at the time of testing was appropriately assessed as 1:5,000, she would not be classified as at high-risk for fetal trisomy. The data underlying this recommendation comes from the Non-Invasive Chromosomal Evaluation (NICE) Study that only included patients with an increased risk of fetal aneuploidy, with a presumed prevalence of trisomy 21 of 1:50 in their cohort. More recent studies on cell-free DNA testing in a low risk or routine population has confirmed [cell-free DNA] cfDNA testing was superior to that of traditional first-trimester screening for the detection of trisomy 21 in a routine prenatal population, but indicates further study is still needed (Norton, et al (2015). 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 10/10/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 41-year-old male enrollee has requested reimbursement for elastase pancreatic fecal and fecal calprotectin laboratory testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The records document diarrhea-predominant irritable bowel syndrome. This patients provider ordered fecal calprotectin testing to rule out intestinal inflammation and fecal elastase testing to assess for pancreatic insufficiency. Based on the records, careful patient interview and examination may have yielded better targeted studies. In the evaluation of chronic diarrhea, fecal calprotectin is sometimes used in clinical practice to distinguish inflammatory versus functional causes of diarrhea, particularly in pediatric populations. The records do not support concern for inflammatory bowel disease in this patients case. Therefore, fecal calprotectin laboratory testing performed on 8/03/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 38-year-old male enrollee has requested reimbursement for polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The submitted records indicate that the patient had limited comorbidities at the time of the disputed testing, and that his diarrheal condition was self-limited and uncomplicated. Provided documentation fails to support fever, dysentery, severe dehydration, or that patient is an immunocompromised individual. Rather, the patientas record supports immunocompetency, no blood in stool, and a clinical history suggestive of a narrowly-focused infectious etiology. The medical evidence does not support the services at issue over otherwise targeted stool analysis for this patientas condition. Therefore, polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a six-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg click easy cartridge.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition The physician reviewer found this patient was born small for gestational age and has failed to catch up in weight and length since birth. He has low growth factors and a small pituitary gland as well. Per the medical evidence, sustained postnatal growth failure in children who have been small for gestational age is considered an indication for growth hormone treatment in children. Provocative growth hormone testing is not required for diagnosis and treatment for this indication.  Therefore, the requested Saizen 8.8 mg click easy cartridge is likely to be more effective 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 1

A 22-year-old female enrollee has requested reimbursement for the blood testing (Prometheus Anser IFX) performed on 4/26/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the patient is a 22-year-old female with stenotic ileocolonic and perianal Crohns disease diagnosed in 2012. She has been maintained on Remicade therapy since 2012, with doses varying from 5 mg/kg every eight weeks to 10 mg/kg every four weeks. Remission was achieved in January 2013. Per the office note dated 3/2/16, the patient was experiencing no gastrointestinal symptoms, had no active perianal disease or bleeding, and stools were formed and 1-2 per day in the setting of a normal C-reactive protein. On 4/28/16 Prometheus Anser IFX testing showed detectable serum infliximab (8.7 ug/mL, reference <1.0) and undetectable antibodies to infliximab (<3.1 U/mL). The patient has requested reimbursement for blood testing (Prometheus Anser IFX) performed on 4/26/16. The Health Insurer has denied this request as investigational. The blood testing (Prometheus Anser IFX) performed on 4/26/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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. The American Gastroenterological Association (AGA) guideline recommendations on therapeutic drug monitoring in patients with inflammatory bowel disease acknowledged that there exists no defined cut-offs by which to judge low versus high titer anti-drug antibodies. In this case, the provided records do not support that the patients Crohns disease was symptomatically active at the time of the Prometheus Anser IFX testing. As such, the testing at issue 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found in the documentation available for review, the provider does not document a pain diary for the medial branch block done prior to the radiofrequency ablation. The literature is clear regarding how a diagnostic medial branch block should be done prior to radiofrequency ablation; specifically, using a pain diary for the day to verify when the local anesthetic wore off.  Moreover, it is possible the patient would experience the same relief from a steroid injection alone without also having the increased risk from the radiofrequency ablation. No mention of prior failure from facet injections or epidural injections is noted. Therefore, the requested spine nerve treatment is not likely to be more beneficial for treatment of the patients medical condition than other treatment alternatives. 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 




The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) mental health care services provided from 11/9/16 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 behavioral health issues. The physician reviewer found that the documentation provided for review provides insufficient evidence to support that IOP treatment from 11/9/16 forward was not and is not medically necessary for treatment of this patients medical condition. The records report that the patients overall mood had improved, and there was no documentation of self-harming behavior. The patient continues to have frequent mood dysregulation which appears to be a chronic issue. However, there is a lack of data supporting the efficacy of further IOP treatment for her chronic mood dysregulation. There is no indication that she was or is having any medical problems from anorexia nervosa that require frequent monitoring. The provider recommended the patient engage in dialectical behavioral therapy (DBT) and seek a specialist to help with the patients mood dysregulation. Thus, the records indicate that the patient was a candidate for treatment as an outpatient. All told, IOP mental health care services provided from 11/9/16 forward were not and are not medically necessary for treatment of this patients anorexia nervosa, major depressive disorder, and social anxiety disorder. Based on the foregoing discussion, the services 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: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 32-year-old male. Per the history and physical note dated 5/31/21, he had recurrent 
small bowel obstruction thought to be due to Crohns disease, and presented with increasing 
abdominal pain and distention since the prior evening. The patient has requested reimbursement 
for inpatient services provided from 5/31/21 through 6/02/21. 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 that the submitted documentation fails to demonstrate the medical necessity of the services 
at issue. The inpatient level of care was not supported, and the care provided could have been 
provided at the observation level of care. The patient presented with abdominal pain and imaging 
findings consistent with low-grade or partial small bowel obstruction. He had improvement in 
symptoms with  conservative therapy.  Imaging  did  not  show  bowel  ischemia,  and  no  other 
gastrointestinal cause for the inpatient level of care, such as gastrointestinal bleeding, peritonitis, 
toxic megacolon, sepsis, abscess, or other complication was documented. He regained tolerance 
of oral intake without surgical intervention. All of the measures that were undertaken, including 
monitoring, laboratory testing, specialist consultations, colonoscopy, and advancement of diet, 
could have been performed without the inpatient level of care, at the observation level of care. 
Therefore, inpatient services provided from 5/31/21 through 6/02/21 were not medically necessary 
for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 66-year-old male enrollee has requested reimbursement for gene expression profiling of melanomas performed on 3/29/18.  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 melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for patients with high depth of invasion, 0.76 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is very novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, gene expression profiling of melanomas performed on 3/29/18 was not likely to be 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: Upheld

Summary Reviewer 3

A 52-year-old male enrollee has requested authorization and coverage for CPT 43284 (magnetic sphincter augmentation). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that scientific evidence has not been established via well-designed controlled studies with adequate follow-up demonstrating safety and efficacy of the use of the LINX procedure. Evidence arises largely from case series and cohort studies. Direct comparative studies between surgical interventions are needed to better assess the long-term safety and efficacy of this therapeutic intervention in patients. There is lack of randomized controlled trials comparing LINX with other surgical anti-reflux interventions, such as the Nissen fundoplication. Sheu and Rattner concluded that the long-term safety and efficacy of LINX remains to be determined by evaluating and investigating the safety, efficacy and durability of the intervention over time. Adverse events including erosion through the esophagus have been reported in particular cases. The LINX procedure has not been rigorously tested in randomized controlled trials against other alternative therapies. The superior efficacy of the requested services has not been established. Therefore, CPT 43284 (magnetic sphincter augmentation) is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 31-year-old female enrollee has requested authorization and coverage for HyQvia. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypogammaglobulinemia. The physician reviewer found that HyQvia Ig, dosed at once per month infusion intervals, meets the medical necessity criteria for this patient, who has a diagnosis of blood clotting disorder and hypogammaglobulinemia. In the case of this patient, her blood clotting disorder places her at an increased baseline risk for thromboembolic events. Thus, it is clinically reasonable that less frequent dosing intervals would place her at a lower risk for thromboembolic events. It is also clinically reasonable that a less concentrated Ig product, such as HyQvia, poses less of a risk for thromboembolic event. The peer-reviewed literature does support the use of Ig replacement in special circumstances, such as with this patient. The literature advises also for adequate hydration pre-Ig infusions, slowed infusion rates, and use of antiplatelet therapy for patients at risk. Given this patients clinical presentation and history, the requested HyQvia is medically necessary. Based on the foregoing discussion, the requested medication is 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 female enrollee has requested reimbursement for substance abuse residential treatment provided from 6/16/18 through 6/24/18. 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 in this case, the patients abuse of alcohol and alprazolam was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. Her addictive illness, and co-occurring depression, warranted specialty care. However, by mid-June 2018, there was no evidence of a withdrawal syndrome, psychosocial scenario, psychiatric condition or medical illness that would typically require treatment at the residential level of care. The patient was motivated for recovery. Although she was unsure of the viability of the marriage, she had a safe environment conducive to recovery and supportive family. The physician note from 6/7/18 was unremarkable. The patient was mildly anxious, but stable affectively. Her laboratory studies were normal. There was no mention of distress or problems with her medications, which by then included an anti-craving medication, naltrexone. Further, the patient was not actively engaged in psychiatric care prior to admission, and she had no history of substance use specific chemical dependency treatment, such as outpatient counseling, medication assisted therapy, intensive outpatient services, partial hospitalization or placement in a sober living environment. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. There was no evidence to suggest that similarly comprehensive, evidence-based services provided in a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time. All told, substance abuse residential treatment provided from 6/16/18 through 6/24/18 were not medically necessary 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.