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

Summary Reviewer 3


A 65-year-old male enrollee has requested reimbursement for collagen crosslink testing performed on 7/11/15.  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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  This patient has received Prolia.  In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) scan is appropriate to monitor therapy.  The value of monitoring therapy with the use of biochemical markers of bone turnover is controversial.  This is a test that can be variable and subject to timing, dietary intake and lack of assay standardization.  In sum, collagen crosslink testing performed on 7/11/15 was not likely to have been of greater benefit than 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 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. 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 there is sufficient support for the requested services in this clinical setting.  Hyperthermic intraperitoneal chemotherapy has followed debulking surgery in many of the series that have been published with good results.  In one randomized clinical trial by Verwaal and colleagues, cytoreduction followed by hyperthermic intraperitoneal chemotherapy improved survival in peritoneal carcinomatosis of colorectal origin. The results were the same after an eight-year follow-up report.  In sum, the requested hyperthermic intraperitoneal chemotherapy is likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested services are 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

An 18-year-old transgender female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/19/17 through 3/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The medical records indicated that the patient was not actively suicidal. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. In terms of comorbidity, the records support a score of 1. The patient did not have a history of active serious medical issues or substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have strained relationship with family and indicated some mild stress at home. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient 
had some outpatient mental health therapy prior to residential admission but continued to have symptoms of anxiety. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential mental health treatment from 11/19/17 through 3/08/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a nine-year-old female enrollee has requested reimbursement and prospective authorization and coverage for 33 hours per week of applied behavioral analysis (ABA) therapy provided from 5/18/15 forward. 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 autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. ABA has been shown in the medical literature to be effective for children and preschoolers with autism spectrum disorders. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. In addition, Mohammadzaheri and colleagues examined the use of ABA and pivotal response treatment in school age children with autism and disruptive behavior. The authors found these interventions to be very effective in decreasing maladaptive and disruptive behaviors even in school age children. Based on the documentation submitted for review, the patient presents with behaviors of pica and mouthing non-food items, which can be dangerous. The mouthing of non-food items can lead to infections and also to bezoar, impactions, and other events requiring surgical intervention. Furthermore, this patient has made slow progress with her current level of services in adaptive, communication and behavioral domains. Based on the documentation submitted for review a decrease in ABA hours is not indicated. Self-injury is primarily improved with communication skills. The research study by Richards and colleagues showed that the children with the worse self-injury had higher levels of autism symptoms and lower levels of communication skills. The most effective intervention for pica and to prevent surgical interventions is behavioral interventions. Based on the support in the peer-reviewed literature and the severity of the patients behaviors, the request for 33 hours per week of ABA was and is medically necessary for treatment of the patients medical condition.Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 2

A 64-year-old male enrollee has requested reimbursement for the LifeVest provided from 3/31/17 forward. The Health Insurer has denied this request indicating that the device at issue was and is considered investigational for treatment of the enrollees myocardial infarction and congestive heart failure.   The physician reviewer found that based on the records provided, the patient presents status post acute myocardial infarction leading to a reduction in left ventricular ejection fraction to 20-25%. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until approximately 90 days have elapsed where continued left ventricular dysfunction with an ejection fraction of 35% or less is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator before this time has not been demonstrated to improve outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). At this time, a prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. Thus, in this clinical setting, the LifeVest provided from 3/31/17 forward was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the device at issue was not and is 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that in this clinical setting, the standard protocol for an intermediate thickness tumor does not include a work-up with molecular genetic testing. Although gene expression testing has shown some impressive results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. The standard of care in this clinical setting would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There are no clinical studies at this time that show that the results of the molecular testing will make a difference in the treatment of the patient. As such, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 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 22-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) provided from 9/21/16 forward. The Health Insurer has denied this request indicating that the service at issue was not and is not medically necessary for treatment of the enrollees major depressive disorder. The physician reviewer found in this case, continued TMS was and is medically necessary for treatment of the patients medical condition. The Clinical TMS Society recommends considering continuation or maintenance TMS therapy when other established methods of maintenance antidepressant therapy fail to provide a satisfactory sustained pattern of clinical benefit or a patient has a history of frequent relapse (Perera, et al). In addition, several naturalistic studies have demonstrated good tolerability and clinical efficacy of TMS therapy for treatment courses at long-term follow-up (Dunner, et al; Janicak, et al). In this case, the patient has had multiple relapses. He had trialed many medications and psychotherapies with no improvement. He had responded well to TMS maintenance therapy and the treatment was recommended by his treating clinical providers. Thus, it is reasonably expected that the patient will continue to benefit from TMS sessions. Further, there is no evidence suggesting that ongoing TMS would be unsafe. Based on the medical literature, TMS sessions not to exceed two per week for a period of six months and then clinical re-evaluation is appropriate. As such, TMS provided from 9/21/16 forward was and is medically necessary for treatment of the patients major depressive disorder.  Therefore, the service at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/17/15 and 1/12/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that there is a lack of peer-reviewed literature that supports the use of three dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed medical literature. For these reasons, the breast tomosynthesis provided on 12/17/15 and 1/12/16 were 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 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 2

A 23-year-old female enrollee has requested reimbursement for the E0835 - RR continuous passive motion exercise device provided on 9/28/16. The Health Insurer has denied this request indicating that the device at issue is considered investigational for treatment of the enrollees status post right knee surgery. The physician reviewer found that although continuous passive motion is not routinely recommended, the device at issue was clinically indicated for this patient. In this case, the patient presented with a chondral lesion of the medial facet of the patella and the lateral portion of the trochlea as well as an avulsion fracture increasing the likelihood of postoperative arthrofibrosis and stiffness. Continuous passive motion devices have the potential to improve the histological content as well as the rate and volume of chondrogenesis in repair tissue following chondral injury. The use of continuous passive motion can improve the outcomes of cartilage restoration procedures. Furthermore, this patients need for medial patellofemoral ligament reconstruction was associated with additional articular damage as well as an avulsion fracture which would have likely increased the possibility of arthrofibrosis after surgery. As such, the use of the continuous passive motion device starting 9/28/16 was appropriate, reasonable, and likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 51-year-old female enrollee has requested reimbursement for continued inpatient stay from 7/02/19 through 7/15/19. 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 the submitted documentation supports the medical necessity of the services at issue. The patient had an unstable pathologic cervical spine fracture of T1. She underwent the posterior decompression and stabilization procedure on 6/20/19. She underwent the anterior portion of the procedure on 7/16/19.  The patient was hospitalized during the entire period from 6/19/19 through 7/25/19.  During her stay, and up until the secondary stabilization procedure of 7/16/19, she had an unstable fracture. It is for this reason that the patient remained in hospital. This was the safest and most expeditious way to maintain control of both the patients spine as well as her overall health. The medical evidence supports the services at issue in this clinical setting. Therefore, continued inpatient stay from 7/02/19 through 7/15/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 36-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 11/21/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma class and prognosis, in patients who had undergone sentinel node biopsy. There are two very important decisions to be made in the treatment of cutaneous melanoma. The first is whether to do a sentinel node biopsy. There is good acceptance that if the melanoma has a thickness of at 0.8 mm or more, sentinel node should be done. This applies in this case with a thickness of 1.05 mm. DecisionDx-Melanoma testing would not affect this decision. It is unknown whether this patient has had sentinel node done. The next important clinical decision is whether to give adjuvant therapy. For the most part, this is based on the result of sentinel node biopsy, with a positive node being an indication for such therapy. Again, DecisionDx-Melanoma testing has not been shown to be useful in this decision. Furthermore, it is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. The National Comprehensive Cancer Network does not recommend the use of genomic assays in this setting Therefore, DecisionDx-Melanoma testing performed on 11/21/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records do not document other levels of care such as inpatient psychiatric hospitalization, partial hospital treatment, residential treatment, or use of psychopharmacotherapy to address the patients condition. While the review of the literature indicates some effect with wilderness therapy, there is a lack of comparison studies of standard residential treatment to wilderness therapy. A review of the literature indicates that the most effective treatment of attention deficit/hyperactivity disorder (ADHD) is stimulant medication with or without behavioral therapy. Several studies show effectiveness for psychotherapies for disruptive mood dysregulation disorder (DMDD), but further study is needed. All told, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was not likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 59-year-old male who presented to his provider on 9/15/21. The patient has 
requested authorization and coverage for liver cancer radiation therapy using two treatments of 
selective internal radiation therapy (SIRT). The Health Insurer has denied this request and 
reported that the requested service is not medically necessary for the treatment of this patient. 
The physician reviewer found that the submitted documentation supports the medical necessity 
of the requested service. Y90 radioembolization has been shown to be an effective targeted 
treatment  for  tumors  of  the  liver.  In  this  case,  an  applicator  is  used  to  directly  infuse 
microspheres of Y90 into the tumors. These microspheres are delivered through arteries that 
feed directly into the tumor and emit a radionuclide which kills cancer cells. This allows for a very 
targeted dose to be delivered. Liver tissue is highly radiosensitive so targeted therapies are 
critical to ensure lower liver toxicity. At present, Y90 therapy has demonstrated a favorable 
therapeutic ratio with improved overall survival outcomes and low toxicity rates. While there is 
a lack of prospective, randomized trials directly comparing Y90 and other similar targeted liver 
therapies, Y90 has continued to demonstrate a good safety profile. Tsang and colleagues report 
that Y90 was well-tolerated in patients with metastatic liver-dominant neuroendocrine tumors. 
In phase 3 data combining Y90 therapy with systemic therapy in the setting liver metastases, 
Chauhan and colleagues reported that the addition of the Y90 therapy showed significantly 
longer progression-free survival and hepatic progression-free survival when combined with 
chemotherapy or immunotherapy. Current medical literature corroborates the low toxicity and 
improved overall survival data with Y90 therapy. In this case, there are a few key factors to take 
into account. Firstly, the liver is a very radiosensitive organ, making targeted treatment delivery 
critical. Y90 can deliver the radiation dose through the artery in a manner that touches only the 
tumor. This cannot be achieved by external radiation methods such as stereotactic radiation 
therapy (SBRT). Secondly, this patients liver metastases are very large with some of the lesions 
measuring over 17 cm. Neither surgical resection nor external radiation treatment can safely 
treat liver lesions that are this large. Only a directed trans-arterial method can safely deliver a 
targeted treatment in this setting. Overall, Y90 has a track record of improving overall survival in 
the setting of liver metastases with a fairly low toxicity profile. Given the disease burden seen 
within this patients liver, directed Y90 radioembolization with targeting of the liver metastases 
is medically indicated. Therefore, liver cancer radiation therapy using two treatments of SIRT is 
medically necessary for the treatment of this patient.