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

Summary Reviewer 3

A 59-year-old male enrollee has requested reimbursement for platelet-rich plasma injections provided from 7/14/17 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is limited reliable clinical evidence to guide the use of platelet-rich plasma injections. Transient side effects, such as post-injection swelling and pain, short duration nausea and dizziness, have been reported in up to 20% of recipients. Side effects appear to be more common with multiple injection protocols. Long-term benefits of platelet-rich plasma have not been demonstrated yet in the knee. Short-term benefits, lasting from six months to over a year, include functional improvement and pain relief. Such effects have been demonstrated primarily in patients under age 50 with mild to moderate osteoarthritis or recalcitrant patella tendinopathy. There is lack of high quality studies regarding platelet-rich plasma injections in the sacroiliac joint or thumb carpometacarpal joints. The effects of platelet-rich plasma on knee osteoarthritis are quite mixed, and the research is not high quality. The majority of published data suggests better symptomatic relief with early osteoarthritis. Kon and colleagues performed a study of platelet-rich plasma injections in patients with early arthritis comparing the effectiveness of platelet-rich plasma with that of both low- and high-molecular-weight hyaluronic acid injections. The authors concluded that platelet-rich plasma is promising for less severe early arthritis for patients under 50 years of age, but not for more severe osteoarthritis, especially in older patients. Filardo and colleagues compared platelet-rich plasma injections to hyaluronic acid injections in a 192 patient randomized controlled trial where three weekly injections were followed for 12 months. Significantly more post-injection swelling and pain was seen in the platelet-rich plasma group, with no significant differences in outcome. The authors concluded that platelet-rich plasma should not be preferred to viscosupplementation. In this case, the patient was treated with platelet-rich plasma injections to his thumb carpometacarpal joints, knees and sacroiliac joint for the presumed diagnosis of osteoarthritis, although the records did not clearly define the indication. The current medical evidence does not support this treatment modality in this setting. The patient is over the age of 50, and the submitted records do not include radiology reports which grade the degree of osteoarthritis, if present. Thus, platelet-rich plasma injections provided from 7/14/17 forward were not and are not likely to be of greater benefit than other treatment alternatives. Based upon the information set forth above, the services at issue were not and 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that currently, there is a lack of strong prospective clinical data in the medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for esophageal tumors. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). The comparison dosimetry was reviewed, and the major dose metrics for the normal structures are being met with the standard photon plan. Consensus group guidelines do not support the use of proton beam therapy in this setting. Also, there is a lack of level I evidence to support the use of proton beam therapy for the treatment of esophageal cancer. Thus, proton beam therapy is not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 61-year-old female enrollee has requested reimbursement for Collagen Type 1 C-telopeptide blood test that was performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees post-menopausal osteoporosis. The physician reviewer found osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. It is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy X-ray absorptiometry. Bone mineral density (BMD) assessment, via DEXA, is still the criterion standard for evaluation and diagnosis of osteoporosis. However, because changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover, (proteins and peptides, referred to as biochemical bone markers, that are released as a consequence of the physiological action of osteoblasts and osteoclasts) may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents (Eastell et al). Medical evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine (Chestnut et al).  For this reason, the Centers for Medicare and Medicaid Services (CMS) has established a national policy for reimbursement of collagen crosslink testing including indications such as identifying individuals with elevated bone resorption, who have osteoporosis in whom response to treatment is being monitored and predicting response to Food and Drug Administration approved antiresorptive therapy in postmenopausal women. In sum, the disputed testing was clinically appropriate and indicated for evaluation of the patients medical condition.
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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement for code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19. 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 this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, code 81599 (DecisionDx-Melanoma) testing provided on 1/29/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of an eight-year-old male enrollee has requested reimbursement for services by JNK Assessments provided from 9/13/17 through 11/27/17. 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 Colenbrander and colleagues noted that early identification of dyslexia is crucial to ensure that children are able to maximize their educational potential. DuPaul and colleagues described that comprehensive intervention services for students with comorbid attention deficit/hyperactivity disorder and learning disability will require empirically supported treatment strategies that address both disorders and that are implemented across school and home settings. Hebert and colleagues described that children with dyslexia often have related writing difficulties. The authors found evidence of effective remedial and compensatory intervention strategies in spelling, transcription, executive function, and working memory. The medical evidence supports the services at issue in this clinical setting. Therefore, JNK Assessments provided from 9/13/17 through 11/27/17 were medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 23-year-old female enrollee has requested authorization and coverage for FirstStep Plus Cytogenomic Constitutional (Genome-Wide) Microarray Analysis. The Health Insurer has denied this request indicating that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found arraybased comparative genomic hybridization has become standard of care to investigate 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.  Over the last five years, it has emerged as a first-line investigation.  This test has become an important and mainstream tool in the practice of clinical genetics.  Data have now emerged showing that actionable findings from chromosomal microarray justify its use.  All told, the requested services are likely to be of greater benefit 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 4/29/15. 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 testing in dispute was ordered to direct the use of infliximab in this patient with Crohns disease.  However, the use of this testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management 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.  In sum, Prometheus Anser IFX testing performed on 4/29/15 was not likely to have been of greater benefit than other methods of evaluation.  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 3

A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 patient is a 62-year-old female who had a screening mammogram including tomosynthesis on 3/31/16. The patient relayed a complaint of a palpable breast mass.  The report noted no evidence of breast cancer. The Health Insurer has denied reimbursement for digital breast tomosynthesis performed on 3/31/16. Per the Health Insurer, the service at issue was investigational for the evaluation of this patient.
There is sufficient support for digital breast tomosynthesis for the evaluation of this patient. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. 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: Upheld

Summary Reviewer 


A 44-year-old male enrollee has requested authorization and coverage for lumbar spinal fusion. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees lower back pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the procedure at issue. Resnick and colleagues recommend surgery for spinal stenosis for patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability (Resnick et al). Fusion may be supported for segmental instability (objectively demonstrable) including excessive motion, as in isthmic or degenerative spondylolisthesis, surgically induced segmental instability and mechanical intervertebral collapse of the motion segment and advanced degenerative changes after surgical discectomy. Pre-operative clinical surgical indications require completion of all physical therapy and manual therapy interventions, x-rays demonstrating spinal instability, spine pathology limited to two levels, and psychosocial screening with confounding issues addressed. Ghogawala and colleagues reported that the results of recent studies suggest that a patient's pretreatment psychological state is a major independent variable that affects the ability to detect change in functional outcome. In this patients case, the above-noted evidence-based medical guidelines and peer-reviewed criteria have not been met. This patient presents with persistent and worsening low back pain radiating into both lower extremities. He reported difficulty with functional mobility due to right lower extremity numbness and weakness. There are no clinical findings of nerve root compromise correlated with imaging evidence of degenerative disc disease at L4/5 and L5/S1. Discography is of limited diagnostic value. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no imaging evidence of significant facet arthropathy supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. There is no evidence of a psychosocial assessment. Therefore, the requested lumbar spinal fusion is not considered medically necessary for the treatment of this patients medical condition. Based on the submitted documentation and per accepted clinical guidelines, the requested procedure is 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 62-year-old female enrollee has requested reimbursement for corrective footwear provided on 4/09/19. The Health Insurer has denied this request and reported that the equipment at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records document posterior tibial tendon dysfunction and associated stage I flexible flat foot deformity. The patient also has associated pain and gait abnormality. Posterior tibialis tendon dysfunction is an acquired defect that affects 10% of the geriatric population, particularly women. The cause is degenerative changes. There are four primary stages of posterior tibialis tendon with subcategorizations that range from mild to severe. Orthotics and corrective shoes are generally used for stage I and stage II cases, along with nonsteroidal anti-inflammatory drugs (NSAIDs). In this case, the deformity was stage I flexible flatfoot. Therefore, the use of corrective footwear and orthotics was appropriate. Stage III and stage IV deformities require surgery. Thus, corrective footwear provided on 4/09/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 49-year-old female with a history of ex pleomorphic adenoma of her right lacrimal gland. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that this case was previously reviewed, and additional documentation was submitted for reconsideration. The additional documentation includes a letter from the provider and a photon/proton plan comparison. Based on the provided photon/proton plan comparison, the requested proton beam therapy is medically indicated. The photon-based plan results in excessive and potentially dangerous radiation exposure to the patientas right optic nerve and cornea, which will place the patient at an unnecessarily high risk for right eye pain and blindness.  The proton radiation therapy plan is able to significantly reduce the exposure to these right eye structures, and accomplish known treatment planning objectives. The additional records demonstrate that the patient cannot be treated safely and effectively with photon-based radiation therapy. Therefore, proton beam therapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 78-year-old female enrollee has requested reimbursement for emergency health services (99285) provided on 2/28/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. The patient presented on 2/28/17 with abdominal pain that commenced suddenly that morning and was associated with vomiting and increasing abdominal distention. She had a history of an abdominal aortic aneurysm, putting her at risk for dissection. Patients with aortic aneurysms are cautioned to seek immediate medical attention for the sudden onset of abdominal pain. This patients symptoms of worsening abdominal pain with vomiting meets the prudent layperson criteria for an emergency medical condition. Moreover, CPT code 99285 corresponds to an emergency department visit of high severity where there is an immediate threat to life or physiologic function. The code includes a complete history, physical examination, and decision-making of high complexity. In this case, the medical records support CPT code 99285 level of care. This patient is an elderly female with a history of an abdominal aortic aneurysm as well as a prior abdominal surgery. The history of abdominal aortic aneurysm in a patient with abdominal pain requires thorough and detailed history, examination and imaging. This ruled out an aortic dissection, but revealed a small bowel obstruction. This is a life-threatening emergency, necessitating fluid resuscitation and gastric decompression as well as surgical consultation. Therefore, the care and treatment of this patient meets all three components of a CPT code 99285. Thus, the emergency health services (99285) provided on 2/28/17 met prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A representative of a deceased female enrollee has requested reimbursement for inpatient admission in South Korea from 1/1/12 through 1/1/13. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who was diagnosed with leptomeningeal hemangioblastoma.The physician reviewer found that the submitted documentation supports the medical necessity for the services at issue in this clinical setting. There are detailed medical records that document the progression of this patients medical condition which support inpatient admission in South Korea. Moreover, the medical records prior to the hospital admission in South Korea confirm disease progression. The patient has had a longstanding diagnosis of hemangioblastoma and the records show that there was an acute worsening of the disease from May 2011 through June 2011. According to standard practice, the hospital admission rendered in South Korea was medically appropriate due to the acute urgent worsening and progression of her disease.  In a document dated 5/12/16, a treating provider from South Korea noted increased extent of leptomeningeal metastasis in the cerebellum, brainstem, and present in both cerebral hemisphere surface, and spinal cord surface. Thus, inpatient admission in South Korea from 1/1/12 through 1/1/13 was medically indicated in this case. Therefore, for the reasons state above, the services at issue were medically necessary for treatment of this patients medical condition. The Health Insurers denial should be overturned.