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

Summary Reviewer 2

A 55-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and one inpatient bed day. 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 appropriate patient selection is crucial before anti-reflux procedures. On 1/09/19, the patients provider noted the off-drug pH study comes back with normal DeMeester scores, and cannot substantiate the diagnosis of significant reflux. Per the records, upper endoscopy did not document significant reflux esophagitis either. Further, the patient cannot be considered medically refractory to maximally dosed acid suppression. Additionally, the records document significant esophageal dysmotility. The risks, medical appropriateness, or necessity of LINX in the setting of hypertonic esophageal motility disorder is not apparent. In this case, the requested services are not likely to be more beneficial for treatment of the patients medical condition than available standard therapy, such as weight loss, lifestyle modification, further characterization of lower esophageal reflux dysfunction, and maximal proton pump inhibitor use. In sum, the LINX Reflux Management System (code 43284) and one inpatient day are not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16.  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 the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a threat to himself or others.  Although grandiose, he demonstrated no overt psychosis.  He did not attest to visual hallucinations or auditory hallucinations.  No delusions were apparent, and he was medically stable.  He was goal-directed.  The patient was cooperative with his medication regimen and tolerated it well.  He was deemed to be no elopement risk.  During the dates of service in dispute, he no longer required inpatient treatment and could have been treated at a lower level of care.  All told, acute inpatient psychiatric treatment provided from 2/12/16 through 2/23/16 was not medically indicated 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested authorization and coverage for olaparib (Lynparza) tablet 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the standard of care for prostate cancer includes use of docetaxel or cabazitaxel which have been demonstrated in phase III randomized trials to prolong survival. This patient did not progress on docetaxel and has not been treated with cabazitaxel. Further, additional agents referenced in the National Comprehensive Cancer Network (NCCN) guidelines have greater support for this patients condition than the proposed treatment. Mateo and colleagues reported that Lynparza may provide additional benefit in patients with a BRCA or ATM mutation. However, this patients records document the presence of a FANCA mutation, which has not been shown to increase the effectiveness of Lynparza. For these reasons, the requested Lynparza tablet 100 mg 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 medication 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 2
A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16.  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. In this particular patient, her breasts have been described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on 9/26/16 was likely to have been of greater benefit than other modalities for 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. 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 this patient has obstructive sleep apnea and has mild septal deviation. A drug-induced sleep endoscopy showed no concentric collapse at velum and complete anterior-posterior collapse at some levels. The patient has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. Per the submitted records, this patient is a candidate for the Inspire device, given that he has anterior-posterior collapse at the tongue base. Therefore, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found the RT300 FES is a primary at-home internet linked and remote-clinician monitored intervention for patients with spinal cord injury (SCI) that provides intense electrical stimulation to intact peripheral nerves below the level of the SCI to evoke muscle contractions. Physical activities, like FES, that provide adequate stress to bone, can play a role in the improvement in bone mineral density with the possible prevention or reduction of osteoporosis and a decrease in fractures, two disabling and costly conditions for persons with paralysis due to SCI (Dolbow, et al). In addition, Fazio noted that repeated use of FES can lead to sensorimotor improvements as well as cortical reorganization, changes that cannot be accomplished with passive range of motion alone due to lack of sensory or motor input or activation of motor units, which is essential for motor relearning and neuromuscular reeducation. Thus, the intended in-home use of the RT300 FES cycle will help to remove many of the physical barriers to exercise which is a key factor in promoting regular physical activity in the SCI patient. For these reasons, the RT300 FES cycle provided on 2/10/16 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 equipment 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. 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 various (mostly retrospective) studies of prognostic gene expression profiling (GEP) suggest its role as an independent predictor of worse outcome, although not superior to Breslow thickness or sentinel lymph node biopsy status. It remains unclear whether this GEP profile is reliably
predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that the available clinical studies and recent medical evidence demonstrate that implantation of hypoglossal nerve stimulator can be an effective technique in improving this patients symptoms. The American Academy of Otolaryngology Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with CPAP. Woodson and colleagues indicate that patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of OSA. Clinical studies also recommend that patients benefit from this device when they have a BMI less than 32. This patients BMI was noted to be 31.9. This patient meets clinical criteria for surgical management of the OSA symptoms and has undergone extensive evaluation of the problems associated with sleep deprivation. This patient has trialed CPAP therapy for airway management with failure to control symptoms of OSA, and was intolerant of CPAP. While alternative surgical methods are available, this patient has narrowing of the hypopharyngeal and anterior/posterior palatal airway on sleep endoscopy and meets criteria for the implantation technique. In summary, implantation of hypoglossal nerve stimulator is likely to be more effective for treatment of the patients medical condition than the available alternatives. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not the standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the patients treatment or health outcome. All told, the DecisionDx-Melanoma testing performed on 10/27/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 52-year-old male with a primary brain tumor. The physician reviewer found that 
the  submitted  documentation  does  not  support  the  medical  necessity  of  the  requested 
medication. In this case, the patient has an exceptionally rare glioma subtype called pleomorphic 
xanthoastrocytoma.  These  gliomas  have  a  60%  to  70%  prevalence  of  mutations  in  BRAF, 
particularly  the  V600E  mutation.  This  clinical  situation  is  also  unusual  in  that  the  tumor 
metastasized outside the cranium. The unusual nature of this clinical situation and the overall 
rarity of the tumor means that there is a lack of randomized clinical trials to refer to for supportive 
evidence when deciding on treatment strategies. However, current medical literature does 
support the safety and efficacy of combined BRAF/MEK inhibition in gliomas, especially the 
pleomorphic  xanthoastrocytoma  subtype.  Kata  and  colleagues  report  that  case  series  and 
literature review indicate that dual-drug therapy with BRAF and MEK inhibitors for recurrent and 
anaplastic  pleomorphic  xanthoastrocytoma  with  BRAF  V600E  mutation  may  delay  tumor 
progression without unexpected adverse effects. The National Comprehensive Cancer Network 
(NCCN) guidelines include BRAF/MEK inhibitors in the treatment of gliomas that are recurrent or 
progressive. In this case, the patient requires therapy for recurrent disease with a new metastatic 
site. The oncologist has prescribed dual BRAF/MEK inhibition in the form of binimetinib and 
encorafenib. However, these inhibitors have only been studied in melanoma, with limited 
experience in gliomas. The NCCN guidelines suggest combinations of dabrafenib/trametinib or 
vemurafenib/cobimetinib. In this clinical setting, given that the prescribed dual BRAF/MEK 
inhibition is not supported by the NCCN guidelines, the requested medication is not medically 
indicated. Therefore, Braftovi 75 mg and Mektovi 15 mg are not medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 48-year-old male enrollee has requested reimbursement for polymerase chain reaction (PCR) testing performed on 7/15/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that in this case, the patient presents with fatigue of intermittent duration over several years. The exam findings are unremarkable. The laboratory studies are normal or negative. The records submitted for review do not demonstrate a diagnosis of Lyme disease. He has had negative IgG and IgM serologic assays. Acute Lyme disease may have IgM positivity and late stage Lyme disease has IgG positivity. The medical records submitted fail to provide a clinical indication for PCR testing in the presence of a negative serology. Moreover, there is a lack of evidence demonstrating the presence of either early or late stage Lyme disease. Accordingly, the PCR testing performed on 7/15/15 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 

A 43-year-old female enrollee has requested authorization and coverage for endovenous ablation. 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 there is sufficient support for the requested services in this clinical setting. This patient has symptomatic left great saphenous vein reflux. The vein measures 5.2 mm, and there is reflux of 2 seconds. The clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum recommend a cutoff value of 1 second for abnormally reversed flow (reflux) in the femoral and popliteal veins and of 500 ms for the great saphenous vein, the small saphenous vein, the tibial, deep femoral, and the perforating veins. The current medical evidence supports the requested services in this clinical setting. Therefore, endovenous ablation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 molecular testing has emerged as a promising method for clarifying the gray area of indeterminate thyroid fine needle aspirations, with the aim of reducing the overtreatment of benign nodules and increasing the preoperative detection of malignant nodules that should be treated by a single surgery (total thyroidectomy) rather than a two-step procedure. When molecular testing informs patient management, it should be further integrated with clinical findings and ultrasonographic results. As additional information accumulates to further refine these integrated approaches to patient management, the genetic information provided by molecular tests is expected to increasingly individualize the management of patients with thyroid nodules and cancer. In this patients case, a second thyroid biopsy was not necessary because this test was done as a follow-up of an indeterminate result. A benign result by the ThyGenX/ThyraMIR test has a significant negative predictive value. The medical evidence supports the services at issue in this clinical setting. All told, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 35-year-old male who was admitted on 9/17/18. The records noted acute psychosis due to auditory hallucinations, disorganized behavior, and homicidal threats toward his parents, whom he was living with. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regard to risk of harm, the records support a score of 5 due to homicidal ideation, auditory hallucinations, paranoia and delusions. His ability to decompensate due to noncompliance remained high. In terms of functional status, the records support a score of 5 due to inability to provide for basic needs due to his symptoms. His comorbidity dimension was scored a 2. He had severe mental illness. Due to lack of cooperation with medical staff, other medical conditions were difficult to determine. In terms of level of stress of the recovery environment, the records support a score of 4 due to lack of employment, housing, and inability to manage his day-to-day life. With regard to level of support of the recovery environment, the records support a score of a 3. The records noted involvement of parents and other agencies to help him, but a lack of connection to friends or employers. In terms of treatment history, the records support a score of 4 due to multiple hospitalizations, multiple treatments that failed due to noncompliance due to symptoms of schizophrenia. With regard to engagement, the records support a score of 5 due to refusal to take vital signs, take blood draws, and refusal to participate in group and individual therapy. Therefore, the records support a score of 28. The records support inpatient hospitalization in the patients case. Thus, inpatient behavioral health services provided from 10/01/18 through 11/12/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 50-year-old male who presented with onset of lumbar radiculopathy. The patient 
has requested reimbursement for lumbar spine MRI performed on 4/30/21. The physician 
reviewer found that the submitted documentation supports the medical necessity of the services 
at issue. According to the literature, symptoms of radiculopathy are most commonly associated 
with nerve irritation from a compressive force, such as disc extrusion/herniation, hypertrophic 
spine changes, and sometimes even infectious processes. Berry and colleagues noted, The 
optimal imaging modality for the evaluation of radiculopathy is MRI of the lumbar spine without 
contrast, which can show compression of the nerve root. MRI can guide potential surgical 
intervention. Per American College of Radiology Appropriateness Criteria for the evaluation of 
progressive  symptoms  of  lumbar  spine  pain  and  radiculopathy,  MRI  of  lumbar  is  usually 
appropriate,  the  highest  category  for  recommendation  of  imaging.  The  current  medical 
evidence supports the services at issue for the evaluation of this patients progressive pain and 
radiculopathy. Therefore, lumbar spine MRI performed on 4/30/21 was medically necessary for 
the evaluation of this patient.