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

Summary Reviewer 1


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/15/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found tomosynthesis was approved by the Food and Drug Administration (FDA) in 2011 for clinical use and by the Centers for Medicare & Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended the technique be removed from the investigational category in 2014 due to the advantages this technique brings to radiologists. The tomographic nature of tomosynthesis enables radiologists to get a clearer picture of breast tissue as well as the nature of calcifications as present in this case. This added clarity has resulted in a decrease in false negatives and false positives. Furthermore, the use of tomosynthesis has decreased callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual 2D imaging protocol of mammography was likely of greater benefit to this patient than had she had 2D imaging alone.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: Overturned

Summary Reviewer 


A 43-year-old female enrollee has requested authorization and coverage for breast reduction mammoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees symptomatic macromastia. The physician reviewer found that Breast reduction surgery is medically necessary in this patients case. The patient has well documented symptoms for macromastia and medical treatments have not improved her symptoms. The medical literature indicates that symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for treatment of this condition. Additionally, nonoperative treatments are not likely to improve pain. Instead, the evidence appears to support that surgery may be the most effective treatment for symptomatic relief.  Collins and Kerrigan report that data from the BRAVO (Breast Reduction Assessment Value and Outcomes) study, which prospectively followed 243 patients with symptomatic macromastia, found that nonoperative treatment options did not provide lasting relief from pain. The authors noted  Breast hypertrophy has a significant impact on womens health status and quality of life as measured by validated and widely used self-report instruments including the SF-36, MPQ, MBSRQ, and EuroQol. In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms. In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms. A 2014 study by Strong and Hall-Findlay concluded, We found that reduction mammaplasty has a positive impact on a range of symptoms, even with lower volume resections and regardless of body surface area-calculated adjustments. This adds further weight to the argument that patients should not be denied access to the surgery based on arbitrary volume restrictions. We advocate freedom for the surgeon to make a decision on potential benefits of surgery based around the needs of each individual patient. In this patients case, the records document that she has large pendulous breasts with shoulder grooving and the classic symptoms for macromastia. Breast reduction is a treatment that has been proven effective and curative for symptomatic macromastia. Evidence based peer reviewed studies confirm the benefits of breast reduction surgery for individuals with upper torso pain due to breast hypertrophy. As such, nonoperative treatments are unlikely to improve this patients pain. Therefore, the breast reduction mammoplasty is medically necessary for the treatment of this patients medical condition.
Therefore, for the reasons stated above, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested reimbursement for computed tomography (CT), lower extremity, without contrast material performed on 9/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees ankle pain. The physician reviewer found that determining when a fracture is healed is a routine part of orthopedic clinical care. Typically, serial radiographs are utilized to assess nonunion of a fracture. There is significant variability in the determination of fracture healing radiographically. CT is superior to radiography in the assessment of fracture union. According to the American College of Radiology, CT may be appropriate for the evaluation of ankle fracture in the setting of suspected osteochondral defect. In this case, the patients provider suspected an osteochondral lesion, which is better evaluated with CT or MRI, which can often be occult on radiographs. The provider also suspected nonunion, as the patient had continued pain five months after the injury, which was more than was expected. CT is an appropriate imaging examination in this clinical setting. Thus, CT, lower extremity, without contrast material performed on 9/26/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of an eight-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found that ABA therapy is generally accepted as being an appropriate and recommended treatment for children with autism spectrum disorder. Common features of ABA-based therapies include the objective measurement of behavior, structured control of the environment, and the implementation of procedures based on scientifically established principles of behavior. An extensive body of scientific literature demonstrates the success of ABA-based interventions to decrease problem behavior and increase skills in adults and children with intellectual disabilities and autism. Several meta-analyses indicate that comprehensive ABA intervention leads to medium to large effects in terms of intellectual functioning, acquisition of daily living skills, social functioning and language development in children with autism (Virues-Ortega; Kahng, et al; Lilienfeld). Numerous scientific organizations have concluded that ABA-based therapies are highly effective in the treatment of autism. In this case, ABA therapy is medically necessary to address the patients aggressive behavior, rigidity of routine, and difficulty with social interactions. 
Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for residential treatment provided from 6/02/16 through 6/11/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. On admission, there was no documentation showing that the patient was in withdrawals, or at risk for imminent withdrawals. There was no Clinical Institute Withdrawal Assessment (CIWA) and no vital signs. The patient denied suicidal or homicidal ideation, and there were no signs of her being a danger to herself or others.  There were no emotional, behavioral, cognitive, or impulsive symptoms to would warrant this level of care.  She was medically and psychiatrically stable.  She received aversion treatment, which is not standard of practice in the community. Relaxation treatment, group, individual, and family therapies, as well as the Prozac and Strattera, could all have been administered on an outpatient basis.  There were no signs of impulsivity, aggression, agitation, depression, mania, hallucinations, or other significant symptoms necessitating 24/7 medical and nursing monitoring.  She could have been safely and effectively treated at a lower level of care, along with community supports, such as the Alcoholics Anonymous program and medication-assisted treatment. Thus, residential treatment provided from 6/02/16 through 6/11/16 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 

The patient is a 65-year-old male who experienced a syncopal episode in June 2021. The patient has requested authorization and coverage for a transcatheter aortic valve replacement. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Both the Evolut low risk trial and the PARTNER 3 trial have shown that transcatheter aortic valve replacement is non-inferior and perhaps slightly superior to surgical aortic valve replacement in low surgical risk patients such as this patient. Transcatheter aortic valve replacement has the additional significant advantage over surgical aortic valve replacement in shortening the length of hospital stay. Therefore, the requested transcatheter aortic valve replacement is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of direct applied behavioral analysis (ABA) therapy provided from 8/24/17 through 2/24/18. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the autism spectrum disorder.  The physician reviewer found the request for 20 hours per week of direct ABA therapy provided from 8/24/17 through 2/24/18 were and are medically necessary for treatment of the patients autism. Several medical studies support the efficacy of ABA therapy in relation to life skills and personal appearance for the treatment of autistic adults (Smith, et al; McClannahan, et al). According to the National Institute for Health and Care Excellence (NICE) guidelines for autistic adults, ABA also plays an important role in the treatment of aggression and outburst behaviors in adults. In this case, the patient presents with aggressive and self-injurious behaviors. He continues to require a high level of behavioral supports. Given the support in the peer-reviewed literature, the services at issue were and are medically necessary for treatment of the patients autism. 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 3

A 21-year-old female enrollee has requested reimbursement for greater occipital nerve injection provided on 11/21/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that Occipital nerve blocks are not supported for the treatment of migraine or other type headaches.  The blocks are supported for diagnostic purposes, but are not supported for therapeutic treatment. There is a lack of long-term benefit supported by peer-reviewed literature.  Dilli and colleagues noted that greater occipital nerve blocks did not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. Thus, greater occipital nerve injection on 11/21/17 was not likely to have been more effective than other available 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 


A 23-year-old female enrollee has requested reimbursement for mental health partial hospitalization program (PHP) services provided from 7/27/15 through 9/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees obsessive compulsive disorder and major depressive disorder. The physician reviewer found that this case incorporates elements of the biopsychosocial model of conceptualization and represented a patient burdened with a profoundly debilitating anxiety disorder, with comorbid depression, that impaired multiple domains of functionality. The patients fear of contamination and incessant washing consumed hours of the day and resulted in dermatologic sequelae, intrapsychic distress, occupational problems and interpersonal discord. In accordance with modern psychiatric practice, the patient had first pursued treatment in the outpatient setting. Her illness burden prevented consideration of psychotropic medication and she failed to respond to non-pharmacologic interventions. Thus, she pursued a higher level of care. Such progression is common for patients with severe OCD and consistent with the American Psychiatric Association treatment guidelines. Thus, for the duration of treatment, the patient could not have reasonably been conducted at a less restrictive setting and less intensive treatment would have resulted in inadequate care. While in the program, the patient received gold-standard therapies for OCD, cognitive behavioral therapy and exposure response prevention. Additionally, she was able to defeat her irrational fear and begin a serotonergic medication, which is a first-line intervention for both mood disorders and OCD. The programmatic services provided were for active treatment. The treatment was evidence-based, and reasonably expected to improve her condition and prevent a more serious episode of illness. Further, the duration of services afforded the consolidation of treatment gains while remaining consistent with community practice standards. In sum, the PHP services provided from 7/27/15 through 9/22/15 were medically necessary for treatment of the patients medical condition.  Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of a four-year-old male enrollee has requested reimbursement for the polymerase chain reaction (PCR) testing and homocysteine testing performed on 6/4/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees risk for methylenetetrahydrofolate (MTHFR), Factor V Leiden, and homocysteine mutations. The physician reviewer found that although this patients mother experienced blood clots at an early age and in unusual places, the patient himself is not reported to have thrombosis. The American College of Medical Genetics (ACMG) practice guidelines regarding genotyping of MTHFR do not support testing in this clinical setting. Studies of MTHFR have focused on a wide varieties of conditions, including vascular disease, neural tube defects, mental illness, autism, and cancer. While some studies have found associations, other studies have found no association. Ultimately, the ACMG found that there is insufficient evidence of clinical utility of MTHFR polymorphism testing. The mother reports that she tested negative for the Factor V Leiden mutation. Thus, testing this patient who is asymptomatic was not indicated, particularly in light of the fact that the only person in the family with thrombosis has tested negative. In summary, the PCR testing and homocysteine testing performed on 6/4/16 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 55-year-old male enrollee has requested authorization and coverage for an electrical stimulation device.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the anaplastic astrocytomas and glioblastoma multiforme are high-grade tumors that are best treated with resection, radiation therapy, and chemotherapy.  The standard of care is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide.  This patient has exhausted standard options.  In 2011, the U.S. Food and Drug Administration approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  There is sufficient medical evidence to demonstrate the safety of this device in this clinical setting.  Therefore, the requested electrical stimulation device is likely to be more efficacious than other available modalities.  Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 62-year-old male with prostate cancer. The record noted the patient had an elevated prostate specific antigen (PSA) of 8.5 ng/mL. He had a prostate core biopsy performed that showed adenocarcinoma of Gleason score of 3+3=6, involving less than 50% of the gland. An OncotypeDX test was ordered to better determine adjuvant treatment or observation. The patient underwent testing and has requested reimbursement for the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17. The Health Insurer denied the request for reimbursement. Per the Health Insurer the services at issue were investigational for the evaluation of this patients medical condition. Once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy (i.e., surgery or radiation) and instead, may be followed closely. Current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The prostate Oncotype DX is a gene expression analysis that target genes in the biopsy specimen and generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (Cooperberg, et al). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. Current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. In addition, the National Comprehensive Cancer Network guidelines appear to suggest that the OncotypeDX test is a technique that is able to better stratify patients with localized disease. As such, the gene expression profiling OncotypeDX prostate cancer assay performed on 2/14/17 was likely to have been more effective than any available standard method for evaluating this patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been 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 

The patient is a 74-year-old male with a history of recent treatment for Streptococcus sanguinis endocarditis (ending on 11/25/20) and a recent resection of a colon cancer.  The patient has requested reimbursement for admission and hospital stay from 12/05/20 through 12/10/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records do not demonstrate evidence of serious complications of possible sepsis. The patient did not have a fever, confusion, renal failure or positive blood cultures.  Evaluation on observation status would have been appropriate, and he did not need full hospital admission. Therefore, admission and hospital stay from 12/05/20 through 12/10/20 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  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 there is sufficient support for the service at issue in this patients case. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional imaging alone.  In this case, there was a question of increasing architectural distortion in the left breast, prompting further investigation.  Thus, the addition of breast tomosynthesis was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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.