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

Summary Reviewer 1


A 52-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found appropriate patients for the LINX Reflux Management System are those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials. Without controlled data comparing it to a standard reflux operation, such as Nissen fundoplication, the superior efficacy of the requested services cannot be established.  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 


A 46-year-old male enrollee has requested reimbursement for total disc arthroplasty to cervical vertebral level: C5/6 using Globus Secure-C device on 6/29/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition.The physician reviewer found evidence-based medical peer reviewed literature and guidelines do not support single-level artificial disc replacement in the setting of multilevel cervical degenerative disc disease. This patient presented with significant neck pain radiating into the right upper extremity with severe functional disability. Physical examination documented upper extremity motor and sensory deficits and reflex changes. There was imaging evidence of multilevel severe spinal canal and neuroforaminal narrowing at the C3/4, C4/5, and C5/6 levels. The North American Spine Society evidence-based clinical guidelines for cervical artificial disc replacement (ADR) state that cervical ADR may be indicated for patients with radiculopathy related to single level degenerative disease (either herniated disc or spondylotic osteophyte) from C3/4 to C6/7 with or without neck pain that has been refractory to conservative treatment. Guidelines state that cervical ADR is not indicated in symptomatic multilevel disease (two or more levels) that would require multiple level artificial disc replacement. In this patients case, there was no compelling evidence presented to support the medical necessity of C5/6 artificial disc replacement over the standard anterior cervical discectomy and fusion. Moreover, there was a lack of evidence that the patients symptoms were limited to the C5/6 level. As such, the total disc arthroplasty to cervical vertebral level: C5/6 using Globus Secure-C device on 6/29/16was not medically necessary for treatment of this patient. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 25-year-old male enrollee has requested reimbursement for partial hospitalization program for substance use disorder from 2/17/16 through 6/07/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity for the services at issue.  The patient showed no post-acute withdrawal symptoms.  The records indicated he was maintaining sobriety.  He was not a danger to himself or to others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. The progress notes indicated that he was containing his anger and irritability. He was using his coping skills.  He was medically and psychiatrically stable. He minimized his addiction. He was more cooperative and engaged. He was working on emotional dysregulation and using his coping skills to self soothe and handle stress.  He denied suicidal or homicidal ideation. His parents were supportive. He could have been treated at a lower level of care by 2/17/16. Therefore, the structured 24-hour setting of residential treatment, from 2/17/16 through 6/07/16, was not medically necessary.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 51-year-old male with a history of chronic right knee pain due to advanced tricompartmental osteoarthritis.The patient has requested authorization and coverage for total knee arthroplasty. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the patient has a history of chronic tricompartmental osteoarthritis of the right knee for which a total knee arthroplasty is requested. The disputed issue pertains to the BMI of 36.26 according to the medical records, which necessitates documentation of a weight loss plan according to the Health Insurer. The patient states that his BMI is 32.3. A review of the medical records indicates that the patient is a body builder and a fitness enthusiast who has tried other options and is likely to do well after this surgery. Although obesity is associated with a higher cardiovascular risk, every patient should be evaluated on an individual basis and it should not be an absolute contraindication. In this case, with the history of physical fitness, and the motivation of the patient, the higher BMI in itself is not a contraindication to total knee arthroplasty. Considering the individual circumstances, a good result should be expected from the surgery. There is sufficient support for the requested services in this clinical setting. Therefore, the requested total knee arthroplasty is medically necessary for the treatment of this patient
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 57-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/24/15.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that the medical literature supports the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, breast tomosynthesis performed on 11/24/15 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 48-year-old male enrollee has requested reimbursement for magnetic resonance imaging (MRI) performed on 5/11/15.  The Health Insurer 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 there is a lack of support for the services at issue in this clinical setting.  As stated by Roudsari and Jarvik, in the setting of low back pain (LBP), all of the guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered.  In addition, all agree that for patients with acute LBP and without any risk factor for serious spine abnormalities, imaging within the initial 48 weeks should not be performed.  Per Chou and colleagues, clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy).  In this patients case, the one-day history of low back pain, regardless of whether the patient has a radiculopathy, does not warrant an immediate MRI scan.  All told, the requested MRI performed on 5/11/15 was not medically indicated for the evaluation of this patient.  Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), specific criteria must be met for all patients treated with minimally invasive SI joint fusion. The criteria require documentation of significant SI joint pain, SI joint pain confirmed with at least three physical examination maneuvers that stress the SI joint, confirmation of the SI joint as a pain generator with 75% or greater acute decrease in pain upon fluoroscopically guided diagnostic intra-articular SI joint block using local anesthetic, failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest, physical therapy, SI joint steroid injection, and failure to respond means continued pain that interferes with activities of daily living and/or results in functional disability, as well as a record that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. The peer-reviewed medical literature also supports SI joint fusion as there are well-constructed trials to permit scientific conclusions when these specific criteria are met. Polly and colleagues recently demonstrated that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. As this patient has adequately satisfied all criteria, she is an appropriate candidate for a right SI joint fusion. Accordingly, the requested SI joint fusion is 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: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found serial dilution end point titration technique of allergen testing is an alternative to skin prick testing. According to Boyles, serial endpoint titration showed a higher degree of sensitivity in evaluating skin response in less sensitive reactors  Per Boyle, identifying patients who are less sensitive reactors is important, so that they can be started on immunotherapy.  Per the current medical evidence, serial dilution endpoint titration is an acceptable alternative to skin prick testing for identification of allergens, with the goal of desensitizing patients and eliminating need for sustained anti-allergy medications.  In sum, the services at issue were likely to have been of greater benefit than other modalities.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. 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. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 50-year-old female who presented to the hospital on 5/04/21 with a generalized weakness starting approximately one month earlier, but worsening in the last four days. The patient has requested authorization and coverage for acute rehabilitation admission. 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 that Ethanol is a neurotoxin known to cause cerebral and cerebellar pathology, resulting in cognitive dysfunction, gait ataxia, loss of manual dexterity, and a generalized accelerated functional decline relative to normative expectations for age. The gait problems associated with chronic alcoholic use are generally progressive, and not expected to improve spontaneously through neurological recovery. Rehabilitation measures in the setting of acute on chronic functional disorders with impaired gait and impaired safety awareness, etc., such as in this current clinical setting, can include further medical optimization, endurance building, devising and promoting compensatory strategies, safety promotion, family/caregiver training and finding/fostering a supportive/appropriate residential environment. There is no need, however, for these services to be provided in an acute inpatient rehabilitation facility. There is no proven marginal benefit of high intensity services for this type of rehabilitation over rehabilitation provided in a less intensive setting. The rehabilitation and convalescence related to this condition is a protracted process. Notably, despite the therapy the patient has been undergoing in the facility, her functional gains have been minimal. Intensifying the services is not expected to positively impact her recovery course or outcomes. Therefore, acute rehabilitation admission is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is an 11-year-old male with a history of central precocious puberty (CPP). The 
provider has recommended treatment with Lupron Depot-PEDS 30 mg injection. The Health 
Insurer has denied the requested treatment as not medically necessary for treatment of the 
patients medical condition. The physician reviewer found that Gonadotropin-releasing hormone 
(GnRH) agonists such as Lupron Depot-PEDS are used primarily in the treatment of patients with 
CPP. The goals of GnRH therapy for patients with CPP are to halt pubertal progression and 
progressive physical development, including height for age and differences from age- and sex-
matched peers, and to preserve or reclaim adult height potential (Bangalore, et al.). In this case, 
the clinical presentation and course of this patient are consistent with a diagnosis of CPP. The 
patients abnormally advanced bone age predicted adult height of 177.5 cm is significantly below 
the patients MPTH of approximately 187 cm. Therefore, the requested Lupron Depot-PEDS 30 
mg injection is medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for Sovaldi and Daklinza.  The Health Insurer has denied this request indicating that the requested medications are not medically necessary for the treatment of the enrollees medical condition. 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. However, no reason is provided for ribavirin ineligibility.  The guidelines only recommend Sovaldi and Daklinza therapy for treatment-naive genotype 2 patients who are ribavirin-ineligible.  Otherwise, guidelines recommend Sovaldi and ribavirin as first-line therapy instead.  For these reasons, the requested treatment with Sovaldi and Daklinza is not medically indicated for the treatment of this patient.  Therefore, the requested medications are 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  
The patient is a 52-year-old female with psoriasis and psoriatic arthritis affecting her skin including 
on her palms and soles. The patient has requested authorization and coverage for Cosentyx two 
pens 150 mg/ml pen injector. 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 Cosentyx is a U.S. Food 
and Drug Administration (FDA) approved medication for the treatment of psoriasis.  It receives 
an A rating from the American Academy of Dermatology and National Psoriasis Foundation 
guidelines of care. This medication has good safety and efficacy profiles. It is recommended as 
treatment for chronic psoriasis by the American Academy of Dermatology and National Psoriasis 
Foundation. It has been shown in the FIXTURE study to be a safe and efficacious medication for 
the treatment of psoriasis. The requested medication is medically indicated for the treatment of 
this patients chronic psoriasis, psoriatic arthritis and hand and foot psoriasis. Therefore, Cosentyx 
two pens 150 mg/ml pen injector is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 59-year-old female with alopecia universalis. She has tried and failed treatment with intralesional kenalog, topical calcineurin inhibitors, topical tofacitinib, and squaric acid, for which she had contact dermatitis. The physician reviewer found that according to the most recent published guidelines, the standard of care for the treatment of alopecia totalis/universalis, would include systemic steroids, methotrexate, cyclosporine, and contact sensitization with diphencyprone (DPCP) or squaric acid. The patient already had a side effect preventing further treatment with squaric acid. Few treatment methods have been evaluated by randomized controlled trials to determine the most efficacious modalities to treat alopecia areata (AA). Therefore, it is challenging for clinicians to guide patients regarding the best therapeutic options. Janus kinase inhibitors like Xeljanz have demonstrated beneficial results in treating extensive alopecia. There is evidence to support the use of Xeljanz in this clinical setting. Therefore, Xeljanz 5 mg tablet is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 35-year-old male enrollee has requested authorization and coverage for spine fusion extra segment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient is a 35-year-old male with a history of low back pain.  On 2/09/15, the patient reported low back pain radiating to the right lower extremity of three months duration.  He was status post right L5-S1 microdiscectomy in September 2013. The provider noted that magnetic resonance imaging (MRI) from December 2014 showed a recurrent disc herniation at L5-S1 with narrowing of the right lateral recess.  He was going to physical therapy, which was not helping.  Examination revealed antalgic gait with use of a cane, 5/5 strength to the lower extremities, sensation intact and deep tendon reflexes were 2+ and symmetric.  The patients diagnoses included right S1 radiculopathy and recurrent L5-S1 disc herniation.  On 2/19/15, computed tomography (CT) scan of the lumbar spine demonstrated right L5-S1 herniated disc similar to what might be anticipated from the MRI of December 2014. There was mild annular bulge at L4-5 without focal herniation, spinal stenosis or significant foraminal stenosis.  The provider reports that due to evidence of significant degenerative changes and signs of potential instability at L4-5, the L4-5 would be included in the fusion construct.  Previously, single level fusion at L5-S1 with intervertebral body space was approved by the Health Insurer.  The patient has requested coverage for spine fusion extra segment.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The medical records do not support revision lumbar surgery including decompression and fusion L4 through S1.  In 2013, this patient underwent L5-S1 decompressive surgery and now has a recurrent disc and radicular complaints both subjectively and objectively.  There is evidence on MRI of recurrent disc herniation.  The current medical evidence does not support extending the fusion through L4 or L5 levels as there is no disc pathology at those levels other than disc desiccation.  There is no evidence of flexion/extension instability.  Thus, the superior efficacy of the requested spine fusion extra segment has not been established.  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.