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

Summary Reviewer 1 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low  back  pain.  The  physician  reviewer  found  that  according  to  the  U.S.  Food  and  Drug 
Administration (FDA), intraosseous nerve ablation is intended to be used in conjunction with 
radiofrequency for the ablation of basivertebral nerves for the relief of chronic low back pain of 
at least six months duration that has not responded to at least six months of conservative care 
and is also accompanied by features such as disruption and fissuring of the endplate. This 
patients MRI of the lumbar spine demonstrated fibrotic type endplate change at L4-5 that would 
make the patient a good candidate for ablation of basivertebral nerves. However, the patients 
MRI also showed mild central and moderate left paracentral disc protrusion, moderate left lateral 
recess stenosis, mild right and moderate left foraminal narrowing secondary to disc protrusion 
and mild central canal stenosis. Thus, there are multiple plausible pathologic sources of low back 
pain and finding the source of chronic lower back pain is clinically challenging (Tieppo Francio 
and Sayed). A small minority low back pain diagnoses can be attributed to an anatomical source. 
Overall, the medical evidence is insufficient to support a finding of spinal vertebral bodies as 
being the overwhelming primary generators of the patients chronic low back pain. Therefore, 
the requested intraosseous basivertebral nerve ablation (CPT code 64628) is not likely to be more 
beneficial than any other available standard treatments for the patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is 34-year-old female. The patient has requested authorization and coverage for 
Prolastin-C injection 1,000 mg for 20,000 over 28 days. The physician reviewer found that at issue 
is whether Prolastin-C injection 1,000 mg for 20,000 over 28 days is medically necessary for the 
treatment of this patient. The submitted documentation supports the medical necessity of the 
requested service. Alpha-1 antitrypsin (AAT) is an inhibitor of the proteolytic enzyme elastase 
and is essential for the maintenance of the lung parenchyma. Patients with deficiencies in AAT 
develop lung destruction leading to emphysema and end-stage obstructive lung disease. In this 
case, the patient has a diagnosis of AAT deficiency with phenotype ZZ. AAT deficiency with ZZ 
phenotype  is  characterized by very  low  AAT  levels  driving precocious  emphysema, and  is 
frequently managed with augmentation therapy with Prolastin-C.  In this case, the patients ATT 
levels are at 16 mg/dL, well below the minimum protective threshold of 57 mg/dL, under which 
augmentation therapy is considered beneficial. While clinical guidelines and recommendations 
regarding the specific indications for AAT augmentation may vary, it is generally considered 
reasonable to start augmentation for non-smokers with an AAT genetic variant consistent with 
severe AAT deficiency at an AAT level below 57 mg/dL and with evidence of airflow limitation, as 
in this case. In this clinical setting, the requested medication is medically indicated for the 
management of AAT deficiency in this patient. Therefore, Prolastin-C injection 1,000 mg for 
20,000 over 28 days is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 32-year-old female enrollee has requested authorization and coverage for a prescription for 
Qulipta  60  mg tablets. The  Health  Insurer has  denied this  request  and  reported  that  the 
requested medication is investigational for the treatment of the enrollees headaches. The 
physician reviewer found that in this case, the records document symptomatology including 
photophobia, phonophobia, and nausea lasting hours to days, supporting the diagnosis of  migraines. The FDA approves the use of Qulipta, a medication whose mechanism is related to the 
CGRP, for the management of migraines. Ailani and colleagues noted a significant reduction of 
migraine days with the use of atogepant. Goadsby and colleagues noted nearly four days of 
migraine reduction with the use of Qulipta. While current medical literature supports the use of 
Qulipta as a safe and effective treatment for migraines, there is a lack of evidence supporting the 
superiority of Qulipta to an alternative standard therapy. Therefore, a prescription for Qulipta 60 
mg tablets is not likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the requested services.  Per the medical records, the provider recommended cervical total disc arthroplasty due to concern regarding adjacent segment disease.  However, the literature regarding whether disc replacement prevents adjacent segment disease is equivocal.  There is no clear consensus that disc arthroplasty decreases the risk of developing adjacent segment disease.  In sum, the requested cervical total disc arthroplasty is not likely to be superior over other treatment options.  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: Overturned

Summary Reviewer 

This patient has idiopathic stature and has demonstrated improvement in growth velocity while on GH therapy. Moreover, he has had no adverse effects of therapy and has open epiphyses. Thus, continuation of GH therapy is medically necessary. According to  the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor finding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient met most of these criteria at the time of initiation of GH therapy, and now that he has been receiving GH therapy for over two years with good response and no adverse effects, withdrawal of therapy is not appropriate and may compromise his adult height potential. Accordingly, the requested treatment with Humatrope GH therapy is supported as medically necessary for treatment of this patients idiopathic short stature.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 61-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found following the diagnosis and initial treatment for prostate cancer, it is conventional to obtain sequential prostate-specific antigen levels every six to twelve months for five years.  With a failure of the prostate-specific antigen levels to fall to undetectable levels, or with progressive increases in prostate-specific antigen levels, it is then common to further evaluate the patient with imaging possibly further biopsies.  These additional studies will generally dictate future treatment options.  For the most part, conventional bone scans will suffice.  However, routine bone scans will occasionally not be diagnostic and scanning with sodium fluoride positron emission tomography/computed tomography (PET/CT) scans has been developed as a second-line scanning technique.  In this patients case, the records indicate that the therapy will be dramatically altered depending on the results of the requested PET scan.  If the metastatic disease is limited to a small anatomic region, this can be controlled with focal radiation.  If the disease is more anatomically widespread, then he will undergo more aggressive therapy.  In sum, the requested PET scan is likely to be more effective than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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  
The patient is a 50-year-old female with a history of hyperlipidemia and hypertension. The records 
note a family history of heart disease. The patient has requested authorization and coverage for 
Praluent (alirocumab) 75 mg/ml injection, two injections every 28 days. 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 that the American College of Cardiology (ACC) has developed an expert consensus 
decision pathway regarding the role of non-statin therapies for low-density lipoprotein (LDL) 
lowering for management of atherosclerotic cardiovascular disease risk. Alirocumab (Praluent) 
and evolocumab may be considered if the goals of therapy have not been achieved on maximally 
tolerated statin and ezetimibe in higher risk patients with clinical atherosclerotic cardiovascular 
disease risk or familial hypercholesterolemia. An LDL cholesterol level greater than 190 mg/dl is 
considered a Class I indication for maximally tolerated statin therapy according to ACC guidelines. 
This patient had an LDL level of 196 mg/dl on 7/01/20. Given that this patient was intolerant to 
multiple  statins  as  well  as  ezetimibe,  Praluent  is  medically  indicated.  Therefore,  Praluent 
(alirocumab) 75 mg/ml injection, two injections every 28 days are medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 18-year-old female enrollee has requested authorization and coverage for Focalin XR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees attention deficit hyperactivity disorder, combined type (ADHD). The physician reviewer found the record supports the medical necessity of continued coverage of Focalin XR for treatment of this patients medical condition.  The treating provider has documented that the patient has already failed three of the alternatives included in the Health Insurers prescription drug list:  Adderall XR, Concerta, and Metadate CD. It was also noted that when the patient was placed on Focalin XR, her symptoms had stabilized and were well-controlled. The use of Focalin XR is medically appropriate and consistent with the standard of care in this setting. For these reasons, the requested medication is medically necessary for treatment of the patients medical condition. For the reasons set forth above, I have determined the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 51-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 5/23/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who reported bilateral breast tenderness. The physician reviewer found that 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 diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her mammogram 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 62-year-old female has requested reimbursement for brain MRI and chest x-ray performed on 3/11/19. 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 regarding the patients headaches and vertigo, the patient had an MRI of the brain in 2015 and CT scan in February 2019, which demonstrated similar, nonspecific findings. The office notes indicate that the patients headaches had increased in frequency over the past two years. According to the American College of Radiology (ACR) appropriateness criteria, MRI of the brain without or with contrast is considered usually appropriate in the setting of increased frequency, severity or change in character of headaches. However, MRI is not indicated for evaluation of uncomplicated vertigo. Regarding the patients respiratory symptoms, the patient reported increased recent dyspnea on exertion. According to the ACR appropriateness criteria, chest radiographs are considered usually appropriate as an initial imaging study for evaluation of non-cardiovascular dyspnea. The radiographs can detect chronic or acute findings and guide the possible need for additional imaging studies. Therefore, the services at issue were medically indicated for evaluation of the patients increasing dyspnea and increasing chronic headaches. Thus, MRI of the brain and chest x-ray performed on 3/11/19 were medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for repair of nasal vestibular stenosis performed on 8/10/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient had an acquired nasal deformity and obstruction of nasal breathing. He underwent functional rhinoplasty to restore nasal breathing. Internal valve collapse can lead to nasal obstruction. It is characterized by the collapse during inspiration of the upper lateral cartilages. A narrowing of the angle between the dorsal septum and upper laterals can also contribute, but to a lesser extent. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. This patient had internal valve collapse with improvement with the modified Cottle maneuver. Repair of vestibular stenosis was medically indicated in this setting. The photographs clearly document collapse of the upper lateral cartilage. The medical evidence supports the services at issue in this clinical setting. Therefore, repair of nasal vestibular stenosis performed on 8/10/18 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

excavatum. Removal of the bars was performed 6/21/19. The procedure consisted of exposing the bars through the capsules bilaterally on two bars and extracting the bars after straightening. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Cohen and colleagues noted that Large volume hemorrhage after Nuss bar removal is rare, but may require blood transfusion, thoracoscopic exploration, or open exploration through thoracotomy or sternotomy. Nuss bar removal should be performed in centers capable of these interventions. Bilgi and colleagues stated that Major complications after removal of the Nuss bar occur with some frequencyImmediate management of the complications may require multidisciplinary care. Because of the significant risk of significant complication requiring immediate surgical correction following double Nuss bar removal, the use of an assistant during surgery was medically indicated. Therefore, assistant surgeon services (21899-80) provided on 6/21/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found this patient was diagnosed with non-ischemic cardiomyopathy and was started on medical therapy. Current guidelines recommend three months of aggressive congestive heart failure therapy to see if the ejection fraction improves enough to obviate the need for a permanent implantable cardioverter defibrillator to prevent sudden cardiac death.  There is some likelihood of recovery of left ventricular function in this instance over the initial three-month period with evidence-based medical therapy. Although implantable cardioverter defibrillators have been shown to be beneficial and indicated in both ischemic and non-ischemic cardiomyopathy, the current guidelines did not support implantable cardioverter defibrillator during the dates of service at issue. Per the guidelines, he requires a minimum of three months of evidence-based medical therapy of his left ventricular dysfunction, and then reassessment of ejection fraction prior to consideration for implantable cardioverter defibrillator. The patient is at risk for malignant arrhythmia and sudden death while his ejection fraction is low. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Therefore, the wearable cardioverter defibrillator was likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the device 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: Overturned

Summary Reviewer 2

A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. 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 an individuals personal and/or family history may be explained by more than one inherited cancer syndrome. Thus, phenotype-directed testing based on personal and family history through a multigene panel test may be more efficient and increase the yield of detecting a pathogenic/likely pathogenic variant in a gene that will impact medical management for the patient or at-risk family members. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate
risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. Panel testing, such as with MyRisk, is now considered a standard of care in patients at high risk to carry a genetic mutation, such as this patient. All told, testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement.  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 that he submitted documentation fails to demonstrate the superior efficacy of the requested services.  Evidence-based medical guidelines and peer-reviewed literature do not support the use of an artificial disc replacement adjacent to a prior (multilevel) anterior cervical discectomy and fusion.  This patient presents with intractable discogenic pain and bilateral C4 motor radiculopathy.  He is status post C4-C7 fusion in 2011, with onset of adjacent segment disease at C3-4 in 2012.  Artificial disc replacement at the adjacent level has been requested for functional motion preservation.  However, the use of an artificial disc replacement adjacent to prior cervical fusion is not supported by current literature.  There is a lack of long-term, large volume studies to support the requested services.  Therefore, the requested cervical artificial disc replacement is not likely to be more efficacious than other treatment options.  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: Overturned

Summary Reviewer 


A 52-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1a.  The physician reviewer found that due to the approval and availability of new therapies, clinical guidelines and accepted standards of care were completely revised in late 2014. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. These new guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni is medically necessary for treatment of this patients medical condition. Consistent with these findings, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.