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

Summary Reviewer 3


A 61-year-old female enrollee has requested reimbursement for Collagen Type 1 C-telopeptide blood test that was performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees post-menopausal osteoporosis.The physician reviewer found this patient has failed several therapies. Rather than watching her BMD decline further into the osteoporotic range, it was reasonable to utilize the Collagen Type 1 C-telopeptide to assess for adequate suppression of bone resorption in between Dexa scans. Consistent with the above-cited literature, the use of this test was likely to be more beneficial than any other available mechanisms of monitoring therapy in between the patients Dexa scans. Given the proven clinical utility of the Collagen Type 1 C-telopeptide in this setting, the use of the test was medically appropriate in this patients case. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that this patient has chronic subjective instability and knee pain following a remote ACL reconstruction of the right knee. There are some associated degenerative changes in the lateral compartment. A posterolateral reconstruction was not substantially beneficial. In this clinical setting, a custom orthosis equipped with dynamic tensioning system can lower the strain on the meniscus, limits tibial rotation, and help protect the ACL graft, as well as reduce pain and subjective instability. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was 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 device at issue was 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: Overturned

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment program services provided from 1/21/16 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 condition. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  The treatment record indicates that this patient has severe, chronic difficulties that have recently presented significant difficulty both for him, his family and those around him. This patient is receiving a fairly high level of therapeutic interventions and is responding positively to these interventions.  The treatment plan and psychiatric note document that the patient is improving and benefiting from his treatment. However, he still has significant problems and continues to require intensive treatment at the residential level of care.  This patient has a history of repeated aggression that has the potential to cause serious injury to others, and he has potential for serious risk of harm to his family if he were not removed from home during his treatment.  All told, residential treatment program services provided from 1/21/16 forward were and are medically indicated for the treatment of this patient.  Therefore, the requested services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 51-year-old female enrollee has requested authorization and coverage for 64628  thermal 
destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees low back 
pain. At issue is whether 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the enrollee's condition than any available standard therapy. 
The physician reviewer found that in a single-arm metanalysis to provide an estimate of the 
effectiveness of basivertebral nerve radiofrequency ablation to treat vertebrogenic low back pain, 
Conger and colleagues noted a rate of 65% and 64% for equal or greater than 50% pain relief at 
six and 12 months, respectively. The authors further noted that rates of a 15-point or greater 
Oswestry Disability Index (ODI) score improvement were 75% and 75% at six and 12 months, 
respectively. The authors concluded that there is moderate-quality evidence that basivertebral 
nerve  radiofrequency  ablation  effectively  reduces  pain  and  disability  in  most  patients  with 
vertebrogenic low back pain. Sayed and colleagues report in best practice guidelines that the 
application of basivertebral nerve ablation for patients suffering from vertebrogenic low back pain 
is grounded in a solid foundation of both pre-clinical and clinical evidence. The authors further 
report that the United States Preventative Task Force (USPSTF) gives basivertebral nerve ablation 
a Level A grade, with high certainty that the net benefit is substantial in appropriately selected 
individuals. Fischgrund and colleagues found a reduction of visual analogue scale (VAS) pain 
score, an improvement in ODI scores, and complete pain resolution for 34% of patients at 6.4 years 
following treatment of chronic low back pain with basivertebral nerve ablation as compared to 
sham therapy. Therefore, 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 48-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 10/15/20. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that Guardant Assay is a multigene assay done on the DNA found in blood, presumably shed by cancer cells. In many cancer situations, such as in non-small cell lung carcinoma, it is important to ascertain a variety of mutations, as each may have treatment implications. Generally, it is preferable to assay these genomic changes from a tissue biopsy. However, if this is not feasible or safe, serum based assays are acceptable. This patient had already had a panel assay (Caris) from a tissue sample. In this case, it appears as if Guardant360 was being used to determine if there was cancer recurrence. The medical evidence does not support the services at issue in this setting. If the assay is being used to select a specific treatment, the chances of this being beneficial is very low. Therefore, Guardant360 testing performed on 10/15/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that transcranial magnetic stimulation has been approved by the U.S. Food and Drug Administration (FDA) for use in individuals with major depressive disorder who have not had a satisfactory response to at least one antidepressant trial in the current episode of illness. Furthermore, the FDA has approved transcranial magnetic stimulation for adults with no distinction being made that the adult must be 21 and older, not 18 and older. In this case, the patient has met the criteria for transcranial magnetic stimulation established in current psychiatry guidelines. Therefore, transcranial magnetic stimulation is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, cirrhotic genotype 1 patients who have failed PEG-interferon and ribavirin patients should be treated with Harvoni for 24 weeks.  These guideline recommendations are based on multiple randomized clinical trials. Studies have shown decreased survival with delayed treatment (Jezequel, et al).  All told, the requested medication is 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 53-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/25/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that Breast 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 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Digital breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Therefore, breast tomosynthesis performed on 7/25/16 was not likely to have been of greater benefit than other modalities for evaluating this patient. Based upon the information set forth above, the services at issue were not likely to have been 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 49-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The records document chronic left knee pain due to a history of chondral defects in the patellofemoral joint. Focal chondral defects are common in the patellofemoral joint, are difficult to treat and can significantly impair the quality of life of the affected individuals. The autologous chondrocytes implantation technique has been used and perfected over 20 years with the current U.S. Food and Drug Administration (FDA) approved third generation technique called matrix-induced autologous chondrocyte implantation. 
The study by Niemeyer and colleagues included a total of 6,425 patients who fulfilled the inclusion criteria, 6,273 who were treated with microfracture and 152 who were treated with matrix-induced autologous chondrocyte implantation. In the two years after treatment, 1,271 patients in the microfracture group needed a reoperation, compared with 19 in the matrix-induced autologous chondrocyte implantation group. According to Welch and colleagues, recent evidence suggests that autologous chondrocyte implantation should be considered as a first-line treatment option in select patients. Autologous chondrocyte implantation is an effective means for cartilage restoration. Therefore, the requested autologous chondrocyte implantation is 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 the E0835 - RR continuous passive motion exercise device provided on 9/28/16. The Health Insurer has denied this request indicating that the device at issue is considered investigational for treatment of the enrollees status post right knee surgery. The physician reviewer found there is a lack of medical literature supporting use of continuous passive motion exercise device following ligamentous reconstruction for patellar instability. In addition, there is limited medical literature supporting continuous passive motion exercise following any knee surgery. Moreover, the use of continuous passive motion status post total knee arthroplasty does not have clinically significant effects on active knee flexion range of motion, pain, function or quality of life to justify its routine use (Harvey, et al). Given the lack of support in the peer-reviewed literature, the E0835 - RR continuous passive motion exercise device provided on 9/28/16 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 device 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested reimbursement for the prostate ablation performed on 10/24/17. The Health Insurer has denied this request indicating that the procedure at issue was not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues above 65C so that they are destroyed by coagulative necrosis. HIFU has been increasingly been used for treatment of localized prostate cancer over the last decade. However, there is a paucity of controlled trials available for analysis, and currently no long-term survival data are available. In addition, the National comprehensive Cancer Network (NCCN) guideline indicates that HIFU warrants further study, but has not been demonstrated to result in long-term improved health outcomes. Moreover, the National Cancer Institute does not list HIFU as one of the seven standard treatments for treatment of prostate cancer. Furthermore, the American Urological Association (AUA), American Society of Radiation Oncology (ASTRO), and SUO guideline report that providers should inform low-risk prostate cancer patients who are considering focal therapy or high intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking. All told, the prostate ablation performed on 10/24/17 was not medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the procedure at issue was 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 


A 38-year-old male enrollee has requested reimbursement for a second full-night polysomnography to titrate continuous positive airway pressure performed on 11/12/14. The Health Plan has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient had clinically significant obstructive sleep apnea that was documented within two hours of the start of the sleep study on 9/24/14.  Thus, a split night study with continuous positive airway pressure titration during the same study would have been appropriate.  The purpose of a continuous positive airway pressure titration study is to document the optimal setting of continuous positive airway pressure for patients who meet criteria for continuous positive airway pressure treatment.  The continuous positive airway pressure titration study on 11/12/14 did not result in an optimal continuous positive airway pressure setting, and the result of that study was placement on an auto-titrate continuous positive airway pressure machine within an interval.  There is a lack of support for the services at issue in this clinical setting.  All told, the second full-night polysomnography to titrate continuous positive airway pressure performed on 11/12/14 was 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested reimbursement and prospective authorization coverage for transcranial magnetic stimulation (TMS) treatments provided from 9/20/16 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 major depressive disorder. The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy. The American Psychiatric Association (APA) endorses TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Although bipolar disorder is diagnosed in the medical record prior to the psychiatric assessment from 12/7/16, the records submitted for review fail to show evidence of mania or hypomania. Based on the records submitted, this patient has a unilateral mood disorder complicated by PTSD, marital discord, and a pathological personality organization which is steeped in psychodynamic theory. This would explain the refractoriness to bipolar treatments and the chronicity of symptoms with persistent negative schemas, impaired self-perception and recurrent patterns of maladaptive behavior. The medical record supports the presence of an acute-on-chronic depressive episode in context of major depressive disorder. Although TMS is not indicated for PTSD, its co-occurrence is not a contraindication to the therapy. Considering the clinical documentation, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice.  Further, since this patient responded well to the therapy in the past, it is reasonably expected that another course of TMS will improve her condition and prevent a more serious episode of illness. In sum, the TMS provided from 9/20/16 forward was and is medically necessary for treatment of the patients behavioral health condition. Therefore, 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that POEM is a U.S. Food and Drug Administration (FDA) approved treatment for achalasia. In this case, the patient is status post orthotopic liver transplant which was complicated by biliary leak. The patient is not a candidate for surgical treatment. Given the patients severe achalasia and lack of surgical option, POEM is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. For the reasons provided, the request for POEM and associated inpatient admission are 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 31-year-old female who presented to her provider on 7/15/22 with a flare of truncal 
and facial acne vulgaris. The patient has requested authorization and coverage for Azelex 20% 
cream. The Health Insurer has denied this request and reported that the requested medication 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 medication. There are limited treatments available to control 
acne vulgaris during pregnancy or in patients trying to conceive. Most common topical treatments 
are either contraindicated in pregnancy, such as retinoids, or do not have data to support their safe 
usage in pregnancy. Kong and Tey recommend the use of topical medications as  first-line 
treatment for acne vulgaris in pregnant and lactating women, including antibiotics, such as 
erythromycin and clindamycin, and azelaic acid. Prescription azelaic acid is available in different 
concentrations such as a 15% gel or a 20% cream. There is a lack of head-to-head trials showing 
a clear superiority of using a higher concentration of azelaic acid in a 20% cream versus a 15% gel 
or vice versa. Given that either formulation is a safe and effective treatment in this specific subset 
of patients, the requested medication is reasonable. Therefore, Azelex 20% cream is medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 20-year-old female who has been diagnosed with posttraumatic stress disorder,
major depressive disorder, generalized anxiety disorder, and alcohol use disorder.The
patient has requested reimbursement for mental health residential treatment provided from 3/22/20
through 5/22/20. The Health Insurer has denied this request and reported that the services at issue
were not medically necessary for the treatment of this patient.The physician reviewer found the mental health residential
treatment provided from 3/22/20 through 5/22/20 was medically necessary for the treatment of this
patient.