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

Summary Reviewer 


A 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for radiation therapy for bone metastases.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees metastatic prostate cancer.   The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting.  Based on the information submitted, the provider has not given a sufficient reason for the use of three-dimensional conformal technique in the treatment of this bone metastasis.  Currently, there is a lack of clinical data in the medical literature to suggest that treatment with three-dimensional conformal technique offers a clinical benefit compared to conventional radiation therapy techniques in the palliative setting for uncomplicated bone metastases.  Additionally, for uncomplicated bone metastases, the use of stereotactic body radiation therapy is not medically necessary. There is a lack of clinical guidelines that endorse the use of stereotactic body radiation therapy in the initial treatment of prostate cancer metastases.  All told, radiation therapy for bone metastases was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 34-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy. 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 in this case, due to the tumor location in the high pelvis and lower abdomen, the area that requires treatment is surrounded by a large amount of small bowel. Intensity modulated radiation therapy can be utilized in these cases to improve sparing of the small bowel compared to standard three-dimensional treatment planning. In this case, the provider has submitted comparison planning, which showed the bowel receiving an unacceptably high dose with the standard three-dimensional planning. The bowel dose is significantly reduced with the intensity modulated radiation therapy planning. The delivery of standard three-dimensional planning in this case is likely to result in an unacceptably high risk of complications. The medical evidence supports the use of intensity modulated radiation therapy in this clinical setting to mitigate toxicities from treatment. Therefore, intensity modulated radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 53-year-old female enrollee has requested reimbursement for the ColonSentry testing performed on 1/20/15. The Health Insurer has denied this request indicating that the diagnostic testing at issue is considered investigational for evaluation of the enrollees risk for colorectal cancer.  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines for screening for colon cancer do not include ColonSentry, or similar, testing for average or above average risk individuals. The NCCN recommendations are for either colonoscopy, stool based testing with high sensitivity guaiac based or immunochemical based testing or flexible sigmoidoscopy. There is a lack of medical literature to support the use of ColonSentry for colorectal cancer screening. All told, the testing at issue 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 

The patient is a nine-year-old male with extreme short stature. Per the clinical notes, he has been growing below the third percentile since five years of age. The records document mild subclinical hypothyroidism and negative celiac panel. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a height that is more than 2.25 standard deviations below the mean for age and sex. He has extreme short stature that qualifies for treatment with growth hormone therapy, based on Pediatric Endocrine Society guidelines. This patients bone age gives him an estimated adult height which is significantly below his mid-parental target height of 173 cm. He will not be able to attain the parental height without growth hormone treatment. Therefore, Norditropin FlexPro 15 mg/1.5 ml is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3
A 53-year-old female enrollee has requested reimbursement for collagen cross links testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of fragility fracture The physician reviewer found that the use of bone turnover markers (BTMs) for the treatment of osteoporosis is still being determined.  There are large variations in the results using BTMs with only several being standardized. At this time, the interpretation of how to utilize BTMs are not standardized. National recommendations or guidelines are lacking as to its use in the evaluation and management of osteoporosis. There are multiple recent studies reviewing the use of BTMs. However, its clinical utility for monitoring osteoporosis is limited by inadequate appreciation of the sources of variability, by limited data for comparison of treatments using the same BTM and by inadequate quality control. IOF/IFCC recommend one bone formation marker (s-PINP) and one bone resorption marker (s-CTX) to be used as reference markers and measured by standardised assays in observational and intervention studies in order to compare the performance of alternatives and to enlarge the international experience of the application of markers to clinical medicine, (Vasikaran, et al). A recent review by Lee and Vasikaran did not include BTMs. The authors noted that Measurement of BTMs is currently not included in algorithms for fracture risk calculations due to the lack of data.  Accordingly, the literature fails to demonstrate that the collagen cross links testing performed on 11/17/15 was of greater benefit than the available standard therapy for the evaluation of this patients medical condition.

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: Experimental
Decision: Overturned

Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the Intracept procedure is a minimally invasive procedure of intraosseous basivertebral nerve ablation for treatment of chronic low back pain of vertebrogenic origin with Modic Type 1 or 2 vertebral endplate changes. Khalil and colleagues performed a randomized controlled trial comparing the effectiveness of radiofrequency ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain. A total of 140 patients were involved in this study. The selection criteria included chronic low back pain for at least six months, and evidence of severe degenerative disc disease with Modic Type 1 or 2 endplate changes. Half the patients received the radiofrequency ablation of the basivertebral nerve and the other half received standard care. The minimally invasive radiofrequency ablation of the basivertebral nerve group showed significant improvement in pain and functional improvement at the three-month evaluation. This randomized controlled trial showed the safety and efficacy of the Intracept procedure for patients with vertebrogenic low back pain with Modic Type 1 and 2 endplate changes. This patient has vertebrogenic pain with Modic type 2 changes at L3-4 and L4-5. He has chronic low back pain over six months in duration with failed standard treatment. As such, he is a good candidate for the Intracept procedure. Therefore, the requested spine procedure is likely to be more beneficial for the treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 38-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 10/04/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patients depression is treatment-resistant. Multiple antidepressants and augmentation strategies have not successfully brought on remission. George and colleagues showed that transcranial magnetic stimulation was significantly more likely than sham treatment to produce remission in patients with treatment resistant depression. Avery and colleagues provided evidence that transcranial magnetic stimulation is a safe and effective treatment for major depressive disorder. Connolly and colleagues reported that transcranial magnetic stimulation was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression. Transcranial magnetic stimulation is an effective treatment. It has been approved by the U.S. Food and Drug Administration for the treatment of patients with treatment-resistant major depressive disorder and is consistent with standards of good medical practice. Therefore, transcranial magnetic stimulation is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 47-year-old female enrollee has requested reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the American College of Occupational and Environmental Medicine (ACOEM) state that if manipulation does not bring improvement in three to four weeks, it should be stopped and the patient reevaluated. In this case, while the patient presented with subjective pain, the provider has not documented clinical assessments and evaluations to support continued treatments. Most importantly, the records do not include discussions on objective functional improvement as an indication for the extended duration of care. Per 10/19/15 report, the patient was instructed to use ice as needed and to take NSAIDs at her discretion. The patients diagnosis on 7/6/16 included cervicalgia and pain in right shoulder. Overall, the medical necessity for continued chiropractic care cannot be determined without documentation of objective functional improvement. Therefore, reimbursement for the chiropractic care services provided from 1/27/16 through 7/6/16 were not medically necessary for treatment of this patients medical condition. Based on the records provided, 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: Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  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 the current literature supports the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, digital breast tomosynthesis performed on 8/02/16 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 61-year-old male who has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20.  The patient has requested reimbursement for Oncotype Dx Prostate Cancer Assay performed on 3/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) recommends Oncotype Dx Prostate Cancer Assay post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of NCCN risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. This patient is considered to have low risk disease and would fit these criteria. It is considered a standard of care in guiding treatment decision making. There is sufficient support for the services at issue in this setting. Therefore, Oncotype Dx Prostate Cancer Assay performed on 3/31/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity.  The physician reviewer found that the array-based comparative genomic hybridization, also known as CMA has become standard of care in assessing children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies.  Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype (chromosome analysis) returned normal. However, over the last 10 years it has emerged as a first line investigation.  The yield of this test is 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. The medical literature indicates that this test has become an important and mainstream tool in the practice of clinical genetics.  As early as 2007, its diagnostic utility had been convincingly demonstrated, such that experts in the field were recommending its inclusion in the evaluation of any child with intellectual disability.  More recently, in a retrospective analysis by Henderson and colleagues, the clinical utility of this test was confirmed showing that 12.7% of patients meeting referral criteria had a pathogenic copy number variant identified on microarray, and that half of those results influenced management including pharmacological treatment, cancer-related screening or exclusion of screening, identifying contraindications, and referrals for further evaluation. Data have now emerged showing that actionable findings from chromosomal microarray justify its use.  In particular, Olson and colleagues found at least 5% of individuals with epilepsy had pathogenic copy number variants.  All told, the CMA testing (CPT code 81229) performed on 1/26/16 was likely to have been superior over other standard options. Based upon the information set forth 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: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that patients with chronic migraine headache are frequently refractory to conventional pharmacotherapy, either prophylactic or abortive in nature. While there have been trials with intranasal lidocaine, which also has rapid systemic absorption, there is a body of literature that supports the use of lidocaine infusion with considerable improvement in the severity of the headache, lessened or absent dependence on other analgesic medication, and most importantly cessation of chronic daily headache for prolonged periods of time. The medical evidence supports the requested services and requested medication in this clinical setting. Therefore, lidocaine injection 10 mg and associated inpatient stay are likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 30-year-old female enrollee has requested reimbursement for the Anser ADA serological markers performed on 8/21/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that the Anser ADA serological markers testing performed on 8/21/15 was not likely to be more effective for this patient than other available options. There are few well controlled clinical trials to confirm that use of the adalimumab antibody testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). In addition, it has not been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Generally, diminished or suboptimal response to adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-tumor necrosis factor (TNF) agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser testing. In this case, the patient was noted to be doing well at the time her Anser study on 8/21/15. Given the above, the testing at issue 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 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who has sustained a permanent right brachial plexus injury (BPI) resulting in functional paralysis of his dominant right arm. The patient was involved in a motorcycle accident injuring his upper right arm. The records also indicate that the patient has undergone conservative therapies to improve function of this limb. The patient requests authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the equipment is investigational for treatment of this patient. There is sufficient support in the medical literature for the efficacy of the requested equipment in this clinical setting. The equipment is to assist in upper extremity function for an individual with weakness but not paralysis of the upper limb.  The current medical literature indicates that greater functional ability may occur, for motivated patients, from such a powered exoskeleton equipment when compared to traditional orthosis. The medical records outline extensive rehabilitation attempts in a tertiary care setting leading to the current request for a myoelectric exoskeleton to improve the patients upper extremity function. This patient has tried various standard options like splinting, surgery and static orthoses in attempt to restore function to his right arm. As such, the medical record, in this case, presents compelling evidence for the requested myoelectric orthotic device for treatment of this patients functional paralysis of his upper right limb. In sum, the myoelectric, upper extremity orthosis is likely to be more efficacious than other modalities available for treatment of this patient. Based upon the information set forth above, the requested equipment 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.