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

Summary Reviewer 3

A 45-year-old female enrollee has requested reimbursement for the Decision Dx melanoma test performed on 4/4/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees melanoma. The physician reviewer found the patient was diagnosed with a nevoid melanoma measuring 0.42 mm Breslow depth on the right cheek. She underwent Decision Dx Melanoma gene testing to assess the risk of metastatic disease. The use of Decision Dx Melanoma gene testing is not recommended outside of clinical trials according to the National Comprehensive Cancer Network guidelines. In addition, the testing at issue is not the standard of care in melanoma treatment or work-up. For the reasons provided, the Decision Dx melanoma test performed on 4/4/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 45-year-old female enrollee has requested authorization and coverage for L-methylfolate. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is homozygous for methylene tetrahydrofolate reductase (MTHFR) enzyme deficiency. The physician reviewer found there is sufficient support for the requested medication in this clinical setting.  Folic acid is vitamin B9.  It is converted to L-methylfolate, the active form of the vitamin in the body, by an enzyme, MTHFR.  If individuals lack the ability to convert folic acid, they may be prescribed synthetic L-methylfolate.  It is hypothesized that L-methylfolate may help the body create neurotransmitters such as serotonin, dopamine and norepinephrine, and thus may augment antidepressant medications for those struggling with treatment-resistant depression.  Despite the rather limited data, L-methylfolate is safe and reasonably expected to improve the patients condition in this case.  The patient has trialed many standard therapies for major depressive disorder, to no avail.  Thus, the affective illness can be characterized as treatment-resistant depression.  The patient has a genetic test that demonstrates a defective MTHFR gene which suggests L-methylfolate deficiency.  There are several well-designed studies that demonstrate the benefit of L-methylfolate augmentation.  Further, when considering the favorable safety profile, the potential benefits appear to outweigh the risks of treatment.  Finally, the patient is reportedly in remission on the combination of bupropion and L-methylfolate.  Thus, L-methylfolate is medically indicated for the treatment of this patient.  Therefore, the requested medication 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 28-year-old female enrollee has requested reimbursement for the treatment of dry eye performed on 6/02/15 (codes 68761, 83861 and 92285).  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dry eyes. The physician reviewer found there is sufficient support for the services at issue in this patients case.  The patients dry eye syndrome has not responded to the usual medical therapies, including Restasis drops.  Her provider previously recommended use of artificial tears, omega-3 fatty acid supplements, lid hygiene twice daily and sleeping with a humidifier.  The use of punctum plugs is the next logical therapeutic regimen.  All told, treatment of dry eye performed on 6/02/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 21-year-old female who sustained a traumatic nasal injury playing soccer on 10/02/17 when she was hit in the nose by a studentas hand. The school nurse reported a nosebleed with the nose slightly swollen. The physician reviewer found that Friedman and colleagues stated, aUnderstanding nasal anatomy and physiology are the most important points for successful functional rhinoplasty. Anatomic structures playing major roles in nasal breathing functions include the septum, and internal and external nasal valves, so physical examination of these regions is essential. Planning for functional rhinoplasty involves the
identification of the sites of nasal airway obstruction or old trauma and addressing those regions during the operation with a number of different techniques that have been described.a Physical examination 7/17/20 reported, aThe nasal dorsum continues to be crooked with the tip of the nose pointing to the left sideaWe would recommend a septoplasty as well as consideration for an open reduction of her nasal fracture since the way the fracture has healed, it appears that the dorsum pointing to the left is pulling the anterior portion of the nasal septum to the left as well, creating a rightward deviation of the nasal septum interfering with the nasal airway.a
A photograph dated 10/11/17, nine days after injury, shows right-sided deviation of the nose and nasal bones. An undated photograph shows a reverse C-deformity of the nose with a deviation of the nasal bones to the left, and a compensatory deviation of the nasal tip to the right. The patient underwent authorized septoplasty for relief of breathing obstruction. Photographs were received for review documenting that the nasal deviation was functionally significant. Narrowing of the nasal valve is evident on the left side. The medical history received for review documents the medical necessity of the rhinoplasty in addition to the authorized septoplasty. Based on the medical history received for review, rhinoplasty was medically necessary. Therefore, CPT 30400 performed on 9/16/20 was medically necessary for the treatment of this patient.
The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function or (2) to create a normal appearance, to the extent possible. Per the submitted documentation, the patientas condition constituted an abnormal structure of the body. This abnormal structure of the body was caused by trauma. The surgery was performed to improve function. Therefore, the California reconstructive surgery statute does apply to the patient. Thus, CPT 30400 performed on 9/16/20 was reconstructive in nature.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
A 68-year-old male requested authorization and coverage for UroLift procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees benign prostatic hyperplasia (BPH). The physician reviewer found that the requested procedure (UroLift system) is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials, including prospective, sham controlled, randomized studies, have shown that this procedure is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function.  Compared with transurethral resection of the prostate and photoselective laser vaporization of the prostate, UroLift is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time.  As such UroLift procedure is likely to be more effective than other options for the treatment of this patient Therefore, for the reasons stated above, the requested procedure 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: Upheld

Summary Reviewer 3


A 60-year-old male enrollee has requested reimbursement for the subtalar arthrodesis provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees hallux valgus. The physician reviewer found that the enclosed information and available literature on subtalar arthroereisis for the treatment of adult flexible flat foot do not demonstrate that the subtalar arthrodesis provided on 11/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the medical literature, subtalar arthroereisis demonstrates good efficacy in re-aligning the subtalar joint, and reducing overpronation. However, there is a lack of large population studies to examine the efficacy of this procedure in reducing foot pain. Further studies are also needed to evaluate the long-term efficacy of this implant as it sits in the subtalar joint for many years. Long range analysis of side effects must be studied as well. Currently orthotics, Ritchie braces, and Arizona braces are standard of care for pathologic subtalar joint overpronation and its associated pain. 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 45-year-old male enrollee has requested reimbursement for gene analysis performed on 8/14/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that per the National Comprehensive Cancer Network (NCCN) guidelines, Extraocular recurrence or metastasis of ocular/uveal melanoma should be confirmed histologically whenever possible or if clinically indicated. The NCCN guidelines recommend that providers, Obtain tissue for genetic analysis (screening for mutations that may be potential targets for treatment or determine eligibility for a clinical trial) from either biopsy of the metastasis (preferred) or archival material if the patient is being considered for targeted therapy. Per NCCN guidelines, providers should consider broader genomic profiling if the test results might guide future decisions or eligibility for participation in a clinical trial. For patients with metastatic uveal melanoma, enrollment in a clinical trial is often recommended. The literature is not directive regarding the specific systemic agent(s) offering superior outcomes, but does provide evidence that uveal melanoma is sensitive to some of the same systemic therapies used to treat cutaneous melanoma. The medical evidence supports the services at issue in this clinical setting. Therefore, gene analysis performed on 8/14/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. 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 there currently are three major therapeutic approaches to the management of localized prostate cancer. These include prostatectomy, forms of radiation therapy, and active surveillance, with no specific anti-cancer treatment. Recommendations are made as to these options based on risk stratification, which involves calculating an estimate of the risk for the future development of recurrence. The patients cancer is evaluated using the pathology, prostate-specific antigen (PSA) level and clinical stage. By such a method, patients can essentially be placed into one of four major risk categories, ranging from very low, to low, to intermediate, to high risk. By such categorization, this patient would be placed in the low risk category. A further refinement of risk analysis can be performed with gene panels such as Oncotype DX Prostate testing. This is a 17-gene panel that may assist in predicting recurrence of the cancer after treatment. Increasingly, it is being used in prostate cancer. The National Comprehensive Cancer Network suggests considering such a panel for low to intermediate risk prostate cancer. Therefore, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 51-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 9/29/20. 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 Guardant360 is a multigene and mutational assay done on the DNA found in the blood, presumably shed by metastatic cancer cells. This testing can be used instead of a tissue assay when it is not possible or safe to do a biopsy. There are certain situations where such mutational assay has been useful in selecting therapy, e.g., in non-small cell lung cancer. However, its overall use in predicting which agent might be useful has not been convincingly shown. A randomized study by Le Tourneau and colleagues did not demonstrate advantage to selecting treatment based on an assay versus the oncologistas judgment. As noted by Marquart and colleagues, the percentage of patients who benefit from such an approach appears to be low. In this particular case, a genomic assay had previously been done on the metastatic disease (Foundation One assay). It appears the oncologist ordered Guardant360 as a re-check on the Foundation One findings. There is a lack of real data indicating that the Guardant assay can reliably be used for that purpose. Overall, there is a lack of data to suggest that the Guardant assay is likely to be of clinical benefit in this setting. Therefore, Guardant360 testing performed on 9/29/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for fecal lactoferrin testing performed on 12/06/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the documentation does not reveal that the provider seeks to differentiate between inflammatory bowel disease (CrohnAaas disease and ulcerative colitis) and irritable bowel syndrome. The medical
records does not identify features to support one diagnosis over the other. A gastroenterologist uses the clinical history along with laboratory studies including surrogate studies to obtain clues to ongoing inflammation related to the suspecting an underlying disorder of inflammatory bowel disease. In addition, radiographic studies and endoscopic evaluation are tools that can be used but carry their own potential risks. The patient underwent fecal lactoferrin to assess the level of inflammation.
An elevated fecal lactoferrin is not specific for inflammatory bowel disease. Any inflammatory process within the gastrointestinal tract will result in the activation of the innate immune response and release of calprotectin. Fecal calprotectin concentration has been shown in studies to be elevated in many conditions, including rheumatologic conditions. Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to cause significant increases in fecal lactoferrin levels. Proton pump inhibitors (PPIs) have been associated with significantly elevated fecal lactoferrin levels, regardless of reason for PPI. There is a lack of support for the services at issue in this clinical setting. Therefore, fecal lactoferrin testing performed on 12/06/19 was
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents from 8/13/15 through 12/31/16. 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 that the submitted documentation does not support the services at issue in this clinical setting. Upon admission to the residential facility, the record did not contain notations as to frequent suicidal or homicidal ideation, aggression, self-injurious behavior, abnormal vital signs, documentation of withdrawal from substances, urges to use substances, non-response or adverse response to medications, frequent medication changes,  or difficulty with attending to activities of daily living.  During the admission at the residential facility, the patient was documented as having an anxious and low mood at times.  However, she was more frequently documented as having an appropriate mood and attitude with cooperative behavior. Individual progress notes indicated that the patient had no suicide or self-harm risk.  She was noted to be engaged and participated in group.  Per the psychiatric progress note dated 10/19/15, the patient record noted depression and an episode of self-harm. Subsequent psychiatric progress notes documented the patient as having a good/appropriate mood, no suicidal ideation, and no reports of self-harm. There was a lack of documentation to indicate significant adverse effects to the medications and there were few documented medication changes.  The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014).  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services.  According to the patients clinical history and documentation as outlined above, at the time of admission to the residential facility, the patient met CASII criteria for intensive outpatient services and not residential level of care treatment services. As such, residential mental health treatment from 8/13/15 through 12/31/16 was not medically necessary for treatment of this patients medical condition. (Marshall, et al; AACAP; Mee-Lee and Shulman).
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 1/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found there is a lack of evidence in the peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising technology, there is a lack of peer-reviewed literature supporting its use in this clinical setting. Therefore, the breast tomosynthesis performed on 1/21/15 was not likely to be more beneficial than standard modalities. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 34-year-old female enrollee has requested authorization and coverage for ivabradine (Corlanor) 7.5 mg tablet. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees dysautonomia with postural orthostatic tachycardia syndrome (POTS). The physician reviewer found that the patient has documented dysautonomia with POTS, with inappropriate and symptomatic sinus tachycardia on cardiac monitors which has been severely symptomatic and life-limiting over an extended period. In addition to Florinef and Northera to treat POTS, she has been tried on the standard first-line standard therapies including beta blockers, which were ineffective, and midodrine which caused side effects. She was recently started on Corlanor which has markedly improved her symptomatology and tachycardia. Although primarily used for congestive heart failure (CHF), Corlanor has been used for POTS and inappropriate sinus tachycardia. Although not a first-line indication for POTS, there is significant published data, including a randomized trial on the positive effects of Corlanor in POTS and inappropriate tachycardia syndrome (Page, et al; McDonald, et al; Sheldon, et al). As standard first- and second-line medications have already been tried and the patient continued to have life limiting symptoms or side effects, treatment with Corlanor was reasonable and showed significant clinical improvement. Based on the published data, the failure of other first- and second-line medications, and the excellent clinical response, Corlanor 7.5 mg tablet is medically necessary long-term therapy for this patient and this particular clinical indication. Based on the foregoing discussion, the requested medication 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 60-year-old female enrollee has requested reimbursement for air ambulance services provided on 1/13/15. 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 air ambulance services provided on 1/13/15 were medically necessary for treatment of the patients medical condition. The patients symptoms represent a neurological emergency that warrants treatment at a hospital with expertise in treating stroke and subarachnoid hemorrhage (SAH). In both conditions, delay in treatment leads to a worse outcome. To expeditiously transfer the patient via air ambulance was a medically reasonable and appropriate action. In the case of a SAH, a quick work-up including potentially an angiogram, magnetic resonance imaging, and access to a neurosurgeon is critical and potentially lifesaving. In the case of an ischemic stroke, a delay of 40 minutes would have reduced the potential effectiveness of tissue plasminogen activator (TPA). The original treating facilities did not feel equipped to manage the case; thus a transfer was medically necessary. Transfer by ambulance would have delayed care and potentially placed the patient at risk of death or longstanding functional disability. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.