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

Summary Reviewer 2

A 47-year-old female enrollee has requested authorization and coverage for the LINX procedure. 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 there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Similarly, a best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). In addition, adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment such as surgical fundoplication (Sheu, et al; Ganz). The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the request for the LINX procedure is 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 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 1


A 54-year-old male enrollee has requested reimbursement for radiofrequency neurolysis performed on 4/08/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  In the documentation available for review, the providers plan is to perform a medial branch block first.  Furthermore, the physical examination does not demonstrate any pain coming from the left side.  It is unclear why a left side medial branch block or radiofrequency ablation would be done when physical examination does not corroborate pain coming from this area.  Based on the submitted documentation, it is possible the patient would have experienced the same relief from a steroid injection alone without also having the increased risk from the radiofrequency ablation. There is a lack of support for the services at issue in this patients case.  All told, radiofrequency neurolysis performed on 4/08/16 was not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 36-year-old male with a history of posterior scleritis. The patient has requested 
authorization  and  coverage  for  Acthar  Gel.  The  physician  reviewer  found  that  Scleritis  is 
inflammation  of  the  sclera,  the  wall  of  the  eye,  and  is  frequently  associated  with  the 
rheumatologic/autoimmune spectrum of diseases. It generally presents with significant pain and 
can result in severe vision-threatening problems if left untreated. The first line of treatment for 
uveitis is nonsteroidal anti-inflammatory drugs (NSAIDs). The second line of treatment is steroids.  
Unfortunately, treatment with these agents is not without the risk of side effects such as 
glaucoma and cataracts, as well as serious systemic side effects. This patient has failed to respond 
to both. If the scleritis cannot be controlled adequately and safely with steroids, the third line of 
treatment is a disease modifying antirheumatic drugs (DMARD), such as methotrexate. DMARDs 
likewise  carry  the  risk  of  serious  side  effects.  This  patient  has  also  been  treated  with 
methotrexate, and his scleritis is still not controlled. When steroids and DMARDs are unable to 
control the disease process, then the patient is advanced to the fourth line of agents, which 
includes use of a tumor necrosis factor inhibitor, such as Remicade (infliximab) or Humira 
(adalimumab). Unfortunately, this patients disease has not been controlled even with the 
addition of adalimumab.  Therefore, his provider has recommended that the patient be started 
on the last line of treatment, Acthar Gel. This patient has already demonstrated good clinical 
response to this medication in the past, with resolution of symptoms and without intolerable 
side effects. Although Acthar Gel is not an appropriate treatment for uveitis when used as a first 
or second line treatment, this is not the case with this patient. This patient has been treated with 
every class of medication other than Acthar Gel, and his uveitis is still not under control, despite 
a level of treatment that has already resulted in serious side effects. He requires additional 
treatment  in  an  attempt  to  bring  his  scleritis  under  control.  Additionally,  he  has  already 
demonstrated prior resolution on Acthar Gel. There is sufficient support for the requested 
medication in this clinical setting. Therefore, Acthar Gel is medically necessary for the treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 24-year-old male who presented to the emergency room on 5/21/22 with severe 
right-sided lower back pain and one concerning episode of bloody emesis. The patient has 
requested reimbursement for an inpatient stay from 5/21/22 through 5/23/22. 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 supports the medical necessity of the services at 
issue. Antiphospholipid syndrome is a multisystem disease characterized by arterial, venous, or 
microvascular  thromboses.  Denas  and  colleagues  note  that  patients  with  antiphospholipid 
syndrome are at increased risk for developing coronary artery disease resulting from coronary 
thromboembolism, accelerated atherosclerosis leading to a plaque rupture, or microvascular 
thrombosis. While not all troponin elevations are a result of acute coronary syndromes, all troponin 
elevations are abnormal and in the absence of clinical evidence of ischemia, a search for an 
alternative cause of myocardial necrosis is recommended. Several of these causes require urgent 
medical evaluation, as does an ischemic evaluation in the setting of elevated troponin levels. 
Myocarditis is one such cause, especially given its highly variable presentation, and was on the 
differential in the evaluation of this patients elevated troponin levels.  In this case, the patient was 
at a particularly high risk for thromboses secondary to his antiphospholipid syndrome at the time 
of admission due to the cessation of anticoagulation in preparation for a dental procedure. In this 
clinical setting, given the timing of the patients presentation with stopping anticoagulation and an 
otherwise unexplained troponin elevation, the services at issue were medically indicated to 
evaluate for both ischemic and non-ischemic potentially life-threatening etiologies. Therefore, the 
inpatient stay from 5/21/22 through 5/23/22 was medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested reimbursement for the anesthesia service provided on 9/7/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees risk for colon cancer and polypectomy. The physician reviewer found that the patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in both clinical practice and in the research given a low preoperative physical status classification score (Heuss, et al; Trummel; Redondo-Cerezo, et al). While the billing office stated the patient failed moderate sedation, this prior failure of moderate sedation is not reflected in either the clinical records provided for review. All told, the anesthesia service provided on 9/7/16, was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the service at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 58-year-old female with gastroesophageal reflux disease (GERD). Computed tomography (CT) scan of the abdomen on 3/14/17 showed mild wall thickening of the distal esophagus and a small hiatal hernia. Esophagogastroduodenoscopy (EGD) on 7/11/17 showed and irregular squamocolumnar junction at 40 cm, 1 cm hiatal hernia, scattered erosions in the gastric body and antrum, and normal appearing duodenal bulb and second portion of the duodenum. Biopsies showed acute and chronic inflammation at the gastroesophageal junction, Barretts esophagus, and minimal chronic gastritis. Esophagram on 9/19/17 showed normal esophageal peristalsis, no ulceration or stricture, and episodes of gastroesophageal reflux. EGD on 9/26/17 showed a normal-appearing esophagus, a Hill Grade 2 lower esophageal valve, and mild gastritis. Bravo pH study on 9/26/17 showed an elevated DeMeester score of 39.7, consistent with increased acid exposure. Per the providers note dated 10/9/17, the patient had a partial response to proton pump inhibitor therapy. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX is 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 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for the DecisionDx melanoma gene expression assay provided on 7/29/15. 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 currently, the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx melanoma assay should be reserved for use only in a clinical trial setting. Peer-reviewed medical literature has not demonstrated that the DecisionDx melanoma assay changes treatment options or outcomes. Consequently, the DecisionDx melanoma gene expression assay provided on 7/29/15 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 61-year-old female with prior instrumented lumbar fusion. The patient has 
requested authorization and coverage for percutaneous or minimally invasive sacroiliac joint 
arthrodesis. The physician reviewer found the current medical evidence supports the requested 
services in this clinical setting. Sturesson and colleagues noted significant improvement with 
surgical treatment for chronic sacroiliac joint mediated pain with minimally invasive fusion over 
continued conservative management. Martin and colleagues noted, Minimally invasive 
sacroiliac joint fusion provides clinically significant improvement in pain scores and disability in 
most patients, across multiple studies and implant manufacturers. In addition, Martin and 
colleagues noted, The authors of this manuscript recommend that in order to be candidates 
for an MIS SI joint fusion, patients have at least 3 of 5 positive provocative exam maneuvers, 
report pain consistent with that coming from the SI joint with a positive Fortin finger sign, and 
have a positive response to diagnostic SI joint injections. In this case, the patient has clear 
degenerative changes of the sacroiliac joint with positive temporary response to injection, pain 
noted by a Fortin sign, and 5/5 provocative SI joint tests on exam. The requested services are 
likely to decrease pain and increase function. Therefore, the requested percutaneous or 
minimally invasive sacroiliac joint arthrodesis is medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 24-year-old male enrollee has requested reimbursement for services provided from 5/10/15 through 8/05/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees behavioral health conditions. The physician reviewer found the reason for entry into a wilderness program is unclear.  There is no admitting history or intake, and the records do not document that he was seen by a physician of any specialty. There is no prior psychiatric history. It is unknown if other treatment modalities were attempted in the past at lower levels of care and what those outcomes were.  Mental status examinations were not performed and response to medications does not appear to have been assessed.  In sum, the records do not establish that services provided from 5/10/15 through 8/05/15 were likely to have been more efficacious than other treatment alternatives.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 65-year-old female enrollee has requested reimbursement for autonomic nerve function testing performed on 3/26/15.  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 medical records provided for review do not indicate focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function.  The clinical notes do not document by history the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes.  There is no indication of neuropathic pain being reported in terms of having hypersensitivity or allodynia.  Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms.  The available medical records provided for review does not support the presence of subjective symptoms consistent with autonomic nervous system abnormality or indicate objective findings on physical examination of autonomic nervous system dysfunction.   Therefore, autonomic nerve function testing performed on 3/26/15 was not likely to have been more effective 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: Overturned

Summary Reviewer 2 
 
A 37-year-old male enrollee has requested reimbursement for laboratory testing performed on 
6/05/20. 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 Cutaneous T-cell lymphoma affects the skin and tends to transform and spread. 
Oncogenic microRNAs are stable epigenetic inhibitors often deregulated in the tumor and 
detectable  as  biomarkers  in  non-cellular  fractions  of  peripheral  blood.  The  tumor-specific 
expression of miR-155, miR-203, and miR-205 was shown to correctly diagnose cutaneous T-cell 
lymphoma. The studies demonstrate that these microRNAs can be used as plasma biomarkers 
for clinical cutaneous T-cell lymphoma monitoring. Quantitation of the selected microRNAs in 
plasma of the patient was a specific and straightforward approach for evaluating his cutaneous 
T-cell lymphoma activity. Therefore, laboratory testing performed on 6/05/20 was likely to have 
been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 63-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 3/08/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is unknown if the DecisionDx-Melanoma assay can be used to make clinical decisions. Thus, DecisionDx-Melanoma testing provided on 3/08/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for sTMS mini device provided on 8/06/18. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that migraine is a disorder which affects approximately twelve percent of the population. Its severity varies from patient to patient from a benign to a severe debilitating disease state.  This patient has both episodic acute and chronic migraine. Although he has not responded well to Pamelor as well as triptan medications for migraine therapy, there are several other options with good evidence of effectiveness that the patient had not tried and failed in both preventative and abortive categories. While sTMS mini device has shown some effectiveness in migraine, there is a lack of evidence to suggest it is more effective than other established therapies, many of which the patient has not tried. Per the medical evidence, sTMS may be appropriate for patients who respond poorly, cannot tolerate, or have contraindications to pharmacotherapy. At this time, there is a lack of support for the device at issue in this clinical setting. Therefore, sTMS mini device provided on 8/06/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticariaThe physician reviewer found that there is a lack of support in the medical literature for LHR test in a clinical setting for the evaluation of chronic idiopathic urticarial (CIU).  There is some utility of the LHR test as a research tool. Current evidence does not support routine clinical use of autologous serum skin testing or for LHR/basophil histamine responsiveness for the diagnosis of CIU. Chronic urticaria index is a test which consists of basophil (leukocyte) histamine release assay. If the test is positive (index greater than 10), the patient may have chronic autoimmune urticaria.  The test is nonspecific.  It measures only histamine release from the patients cells and compares it to a normal control. It does not measure antibodies or autoantibodies.  Patients with a chronic form of urticaria with a positive functional anti-FceR test result likely have an autoimmune basis for their disease. A positive result does not indicate which autoantibody is present. This LHR test is usually combined with thyroid function, antithyroid microsomal titers, and peroxidase antibody titers.  The result is reported as an index value. The reference range for a healthy non-CU population is less than 10. Values greater than or equal to 10 indicate that donor basophils were stimulated by patient serum to release histamine. The larger the value, the more histamine released. The CU index test (basophil histamine release test, AKA, Leukocyte histamine release test) has not been approved or cleared by the U.S. Food and Drug Administration. Although commercial assays are now available, the utility of testing for basophil histamine release and autoantibodies to the high-affinity IgE receptor or autoantibodies to IgE have not been established. Whether detection of basophil histamine release or autoantibodies identifies a clinically unique population or will lead to a change in management is also currently unclear. The American Academy of Allergy and Immunology guidelines for this test indicate it is primarily used in a research setting. All told, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to be more effective than the available standard methods of evaluating this patient. Therefore, for the reasons stated 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