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

Summary Reviewer
 
The patient is a 20-year-old male with a history of opioid use disorder, amphetamine use disorder, sedative, hypnotic, or anxiolytic use disorder, major depressive disorder, and generalized anxiety disorder. The patients onset of substance use was at age 15 with opiates, benzodiazepines, cannabis, and amphetamines. He has a history of two prior residential admissions and an intensive outpatient program, which were quickly followed by relapse upon discharge.  Prior to the admission in question, the patient reported using half a gram of heroin and unknown amount of cannabis daily for three to four months. He was admitted to a residential treatment program on 4/25/17 and discharged on 7/24/17. During admission, the patient participated in individual, group, family therapy and medication management. The patient has requested reimbursement for substance abuse residential treatment provided from 5/22/17 through 7/24/17. The Health Insurer denied this request and reported that the services at issue were not medically necessary for treatment of this patients medical condition. This denial is the subject of this appeal and determination. The submitted documentation supports the services at issue in this clinical setting. Per the provided documentation, by 5/22/17, the patient still remained symptomatic. The patient was documented as having strong urges to use, irritability, daily mood swings, anxiety, restlessness, and difficulty with sleep. He was described as being somewhat disengaged in the program.  The patient was noted to have limited education and was homeless due to being kicked out of his sober living house. The American Society of Addiction Medication (ASAM) Criteria, a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive environment but safe treatment setting (Mee-Lee and Shulman). The guidelines also recommend that length of service should be determined by the patients progress with his treatment plan as determined by the patient and treatment providers. The medical research indicate that individuals with substance use disorders often need longer term care due to the relapsing and chronic nature of the disorders (Manuel, 2017). By 5/22/17, this patients records did not demonstrate that he was ready to be discharged to a lower level of care. Residential substance abuse treatment has been shown to improve substance use outcomes (Manuel, et al, 2017).  Based on current medical literature, ASAM criteria, and the patients documented clinical history, this patients admission to the residential level of care from 5/22/17 through 7/24/17 was medically necessary (Mee-Lee and Shulman; Ali et al; Gray and Squeglia; Manuel, et al).
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 62-year-old female with a diagnosis of generalized anxiety disorder per the submitted documentation. The patient described her condition as complex trauma.  It appears that the patient has been working with a therapist in the outpatient setting. The trauma history, longitudinal illness burden, and extent and outcome of previous and/or concurrent treatment interventions were not included in the medical records. The patient has requested reimbursement and prospective authorization and coverage for standard outpatient treatment two times per week from 9/05/17 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 this patient. The Health Insurer has approved standard outpatient treatment once per week from 9/05/17 forward as an alternative. This denial is the subject of this appeal and determination. Psychotherapeutically, current practice emphasizes aggressive treatment of psychiatric symptoms in the acute phase of illness followed by less frequent services in the maintenance phase to foster patient autonomy and consolidate recovery.  Thus, it is not uncommon for transient weekly, or even twice- and thrice-weekly, sessions to be medically necessary in the treatment of anxiety and trauma-related disorders. The contemporary treatment armamentarium for both conditions offers many different evidence-based psychotherapies, such as cognitive processing therapy, prolonged exposure, eye movement desensitization and reprocessing, cognitive behavioral therapy, psychodynamic psychotherapy, mindfulness training and interpersonal therapy.  Regardless of the modality, any therapy must be reevaluated for effectiveness and goal progression during protracted treatment courses. With that in mind, the documentation provided in this particular case lacks critical clinical input to support the requested services. Most notably absent is a comprehensive treatment plan. An individualized and up-to-date treatment plan is a crucial patient-centric document that develops and organizes interventions aimed at maximizing functionality as well as helping a patient set specific goals and measurable objectives appropriate to his or her impairments and symptom severity. Based on the documentation provided, there is no evidence that less frequent clinical services, perhaps augmented with self-help programming and sub-clinical activities in the community, would be inadequate or unsafe to treat the patients condition. Further, weekly therapy visits align with community practice standards.  Accordingly, standard outpatient treatment two times per week from 9/05/17 forward were not and are not medically necessary 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 21-year-old male enrollee has requested reimbursement for a PET scan performed on 7/23/19. 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 the records document the rare situation of a high grade soft tissue sarcoma of the heart in a young patient. There is a lack of specific guidelines as to the best way to follow him to detect recurrence. However, there is some literature concerning the use of positron emission tomography (PET) scanning in the follow-up of high grade sarcomas in general. Pastorini and colleagues concluded that PET scan is indeed useful, although Roberge and colleagues cast some doubt on the routine use of PET. Thus, it remains somewhat controversial. However, in this rare circumstance of a very high grade sarcoma in a young patient, PET was likely to have been of benefit to detect and/or rule out recurrent disease. Therefore, PET scan performed on 7/23/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 52-year-old male who presented to his provider on 12/27/21. The records noted 
sleep apnea diagnosed by sleep study in June 2021 and an apnea-hypopnea index (AHI) of 64. The 
patient has requested authorization and coverage for hypoglossal nerve stimulation. The Health 
Insurer has denied this request and reported that the requested service 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 submitted documentation does not support the medical necessity 
of the requested service. The U.S. Food and Drug Administration (FDA) approves the use of the 
Inspire Upper Airway Stimulator for the management of moderate to severe obstructive sleep 
apnea, for patients with AHI greater than 15, aged 18 year and older, with an inability to tolerate 
positive airway pressure (PAP) therapy. The manufacturer of the device, at the time of FDA 
approval, had noted that this device had not been thoroughly tested in individuals with a BMI over 
32 kg/m2. While the FDA approval does not exclude obese patients, current medical literature 
includes only one study evaluating the Inspire implant in obese patients. Huntley and colleagues 
concluded that there was no difference in patients with BMI above or below 32 kg/m2 in response 
to the Inspire implant. However, there is a lack of other studies to support these findings of safety 
in this population. A surgical assessment, performed via a drug induced sleep endoscopy (DISE), 
did confirm anatomic findings which would be favorable and amenable to response from the 
Inspire implant. In this case, while the patient meets a majority of criteria for the requested service, 
including being over age 18, with anatomic findings on DISE amenable to Inspire treatment, an 
inability to tolerate PAP therapy, and a diagnosis of severe obstructive sleep apnea, the patient has 
a BMI of approximately 35 kg/m2. In this clinical setting, given that the patients BMI makes him 
a poor candidate for surgical intervention based on the current available literature, the requested 
service is not medically indicated. Therefore, hypoglossal nerve stimulation is not medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
A 43-year-old male enrollee has requested reimbursement for injection(s), platelet rich plasma, 
any site, including image guidance, harvesting, and preparation when performed, on 3/7/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational 
for the treatment of the enrollees left elbow pain and bicipital tendinitis of the left shoulder. The 
physician reviewer found that in this clinical setting, the PRP injection at issue was not likely to  have been more beneficial than standard therapy with a physical therapy program. In fact, in a 
follow-up visit dated 4/30/22, the records noted no significant improvement of pain  post 
injection and the provider recommended a functional assessment with physical therapy. Notes 
dated  6/13/22  reported  that  the  physical  therapy  program  provided  addressed  specific 
musculoskeletal dynamics along with the provision of a home program. Case reports on the use 
of PRP injections for tendinitis generally show resolution of symptoms over time, however, the 
reported  outcomes  do  not  state  that  the  injections  treated  the  primary  etiology  of  the 
tendinopathies. Rather, there is an association inferred between the time of injections and 
reported symptom relief. There are no current guidelines regarding the use of PRP injections for 
tendinopathies. In a review of current literature on PRP for elbow pathologies, Kwapisz and 
colleagues report that their results showed that more studies on larger cohorts, with comparable 
formulations, and with longer follow-up are required to give optimal suggestions concerning the 
use of PRP in elbow pathologies. More research is needed regarding the indications, efficacy, 
post injection therapy services, and specific techniques of harvest and delivery of the service at 
issue.  Therefore,  injection(s),  PRP,  any  site,  including  image  guidance,  harvesting,  and 
preparation when performed, on 3/7/22, was not  likely to have been more beneficial for 
treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 57-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 8/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this patients case. DecisionDx-Melanoma is a 31-gene expression profile test for predicting the risk of recurrence of skin melanoma. The National Comprehensive Cancer Network guidelines note that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, routine prognostic genetic testing of primary cutaneous melanoma before or after sentinel node biopsy is not recommended outside of a clinical trial. The current medical evidence has not demonstrated that the test is more beneficial than standard of care. Thus, DecisionDx-Melanoma test performed on 8/17/17 was not likely to have been superior over other methods of evaluating this patient. 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: Upheld

Summary Reviewer 3


A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found the effectiveness of Anser IFX in the management of Crohns disease compared with conventional courses of action remains unproven in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing.  Based on the clinical literature, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 62-year-old female has requested authorization and coverage for spine nerve treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees back pain. The physician reviewer found the current medical evidence does not support the requested services in this clinical setting.  Per the records, this patient has received only a single set of diagnostic lumbar medial branch blocks. Manchikanti and colleagues noted the evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. Additionally, the literature supports the use of a second set of diagnostic medial branch blocks. In this patients case, the pain relief did not exceed 75%, and a second set of diagnostic medial branch blocks was not performed. Therefore, the requested spine nerve treatment 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

The patient is an 18-year-old female with a history of major depressive disorder, recurrent severe without psychosis. The patient was admitted to an inpatient facility on 1/11/18 after reporting three weeks of worsening suicidal ideation and plan to jump off a bridge.  The patients history is significant for self injurious behavior from ages 12 to 15, an overdose attempt in June 2017 without hospitalization, an inpatient psychiatric hospitalization in August 2017 due to suicidal ideation, two months of intensive outpatient program treatment in October 2017, outpatient mental health treatment with a psychiatrist and therapist and medication trials of sertraline and escitalopram. During the patients recent inpatient admission, the patient was treated with venlafaxine ER, bupropion XL, mirtazapine, hydroxyzine, aripiprazole, and vortioxetine. She was discharged from the inpatient facility on 2/5/18 with plan to attend the Transitional Age Youth Intensive Outpatient Program. The patient has requested reimbursement for mental health inpatient stay from 1/29/18 through 2/5/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the patients behavioral health condition. This denial is the subject of this appeal and determination.  The submitted documentation supports the services at issue in this clinical setting. Based on a review of the medical records, the patient was not stabilized and remained symptomatic on 1/29/18. On 1/28/18, the patient was documented as refusing meals.  She was noted to have a flat affect and was withdrawn. The patient reported continued feelings of depression, guilt, and hopelessness with suicidal ideation.  On 1/29/18, the patient was documented as being depressed and withdrawn and feeling hopeless and helpless.  The patient endorsed continued suicidal ideation, isolated from peers, and was not fully participating in group activities. The patient continued to report depressive symptoms including recurrent suicidal ideation and anxiety symptoms up until the point of discharge at which time she reported improvement in her mood.  The patient had medication dose adjustments and changes to address her persistent symptoms. Research has shown that patients, with similar histories to the patient in this case, are at risk for early readmission especially if not stabilized at the time of discharge (Donisi, et al). The patients clinical status, in addition to current medical literature, support the mental health inpatient stay from 1/29/18 through 2/5/18 as medically necessary.  Therefore, for the reasons stated above, 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 48-year-old male who reports left leg pain. The patient has requested authorization and coverage for endovenous ablation. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the documentation supports the medical necessity of the requested services. The records note pain in the left lower extremity that is impacting the patients quality of life and activities. There is documentation of significant reflux in the vein to be treated and an absence of deep vein thrombosis. There is documentation of adequate arterial perfusion to the lower extremities bilaterally. Additionally, the notes document that the symptoms have been recalcitrant to conservative efforts. Therefore, the requested endovenous ablation is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 54-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 hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with a viral load below six million IU/mL can be treated with Harvoni for eight weeks. These 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 hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, 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

The patient is a 39-year-old female with a child diagnosed with Coffin-Siris syndrome. She underwent testing during a subsequent pregnancy. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is sufficient support for the services at issue in this clinical setting. When counseling patients with the sole risk factor of advanced maternal age, in the first trimester of pregnancy, several genetic testing options are discussed. These options include no testing or a first trimester screen, usually called the QUAD screen, which consists of serum markers typically done between 15 and 19 weeks. Both tests would also be appropriate to discuss with women under the age of 35. Additionally, for women over the age of 35, since their individual risk of genetic abnormalities increases, additional screening options and invasive testing such as amniocentesis or chorionic villus sampling should be offered along with genetic counseling. This patient desired screening for her risk of trisomy, given her advanced maternal age. She also wished to screen for the SMARCA4 gene mutation given a history of a child with a syndrome related to this gene mutation. Given this patients age, previous pregnancy/birth history, and increased risk above the population risk for a specific gene mutation that can have significant and grave consequences, the services at issue were medically appropriate. In sum, SMARCA4 gene mutation and chromosome testing performed on 8/14/17 were likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.