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

Summary Reviewer 2

A 30-year-old female enrollee has requested reimbursement for bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the non-surgical treatment is the initial treatment of choice for symptomatic hallux valgus deformity. Shoe modification, padding and local application of ice to symptomatic bunion are reasonable initial conservative options. Orthotic devices to control documented biomechanical dysfunction may be considered as conservative or post-surgical options. Surgical treatment is recommended if there is no or little response to non-operative treatment after a six-month trial, or if initial response deteriorates. In general, once surgical criteria has been met, the surgical procedures to be performed are based on the location and the degree of deformity. The two most common radiographic measurement used to choose appropriate surgical procedures include the intermetatarsal angle (IMA) and the hallux valgus angle (HVA). For IMAs less than 13 degrees, distal osteotomy or soft tissue procedure alone are sufficient to correct the deformity. For IMAs greater than 13 degrees, a proximal osteotomy is recommended. There is a variety of osteotomies described to correct the IMA, including the scarf, and no procedure has proved superiority over the other. Regarding the HVA, angles less than 30 degrees can be treated with a distal soft tissue procedure, such as the modified McBride procedure, with or without a chevron osteotomy. For HVA greater than 40 degrees, metatarsophalangeal joint fusion is generally recommended.
In this patients case, operative criteria have been met. Based on the radiographs and the HVA and IMA measurements reported by the treating surgeon, appropriate surgical procedures were performed and are supported by published treatment guidelines for the treatment of symptomatic hallux valgus. In sum, bony correction bunionectomy to treat symptomatic hallux valgus performed on 6/10/19 and 7/29/19 was likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 47-year-old female enrollee has requested reimbursement for back surgery (lumbar spine fusion) performed on 9/3/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain.  A review of the record indicates that the enrollee has a history of low back pain. The enrollee reported that she was involved in a motor vehicle accident in 2011. The enrollee has had conservative therapies with multiple providers to relieve her back pain. Objective findings include radiographic and diagnostic evaluations. The enrollee has requested reimbursement for a back surgery performed on 9/3/14.
The Health Insurer indicates that the documentation provided did not meet the Health Insurers clinical criteria for the services at issue. Therefore, reimbursement for the back surgery was denied.  At issue in this case is whether the services at issue were medically necessary for treatment of the enrollees medical condition.I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for the mobile heart monitor provided on 8/2/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees palpitations. The physician reviewer found that based on the records provided the patient presented with near daily palpitations. In this circumstance, if additional evaluation for a dysrhythmia is thought to be indicated then serial 48-hour Holter monitoring or off-line self-activated or auto-triggered cardiac event monitoring should be sufficient in recording cardiac rhythm during symptoms. There is a lack of documentation to indicate that these devices have already been tried and failed for evaluation of the patients current symptoms. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services has not been shown to improve health outcome compared to standard monitoring techniques. For these reasons, the mobile heart monitor provided on 8/2/17 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 service 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: Upheld

Summary Reviewer 




A 63-year-old male enrollee has requested reimbursement for physical therapy services provided from 1/5/15 through 10/27/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees multilevel stenosis. The physician reviewer found that although a multidisciplinary approach to spine pain including PT may be beneficial, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. The documentation does not indicate that prior extensive PT before 1/5/15 resulted in significant objective increase in overall function. The services at this point do not need to be only under the supervision of a therapist. The patient has had extensive prior PT and should be well versed in a home exercise program. The additional requested therapy is not accepted as specific and effective therapy for this patients condition. Further, the patients expected rehabilitation potential is not significant in relation to the extent and duration of PT services required. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. All told, the PT services provided from 1/5/15 through 10/27/15 were not medically necessary for treatment of this patients medical condition. 
Based on the foregoing discussion, 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 3


A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found it is not likely to be beneficial for this patient to undergo two-level cervical intervertebral disc arthroplasty.  There are general concerns referencing cervical artificial disc replacement.  The properties of wear and the resultant patient response to wear debris from bearing surfaces of hip, knee and spinal disc share the same phenomenon.  There is a predictable level of long-term complications after total hip and total knee replacement, which are attributable to the problems of wear.  The techniques for revision after total disc arthroplasty are controversial.  If the patients implant fails with either edge wearing of the methyl methacrylate portion of the implant or subsidence of the metallic components into the vertebral bodies, then a second anterior approach may become necessary.  This approach would have increased risk since the tissues through which the surgical approach is made have already undergone postoperative scarring.  Studies of longer duration are needed to assess the longer term potential complications of a methyl methacrylate arthroplasty within the cervical spine.  There is documentation in the literature for an increased incidence of dysphasia following a repeat anterior approach to the cervical spine.  A justification and rationale for total disc arthroplasty is the prevention of adjacent segment disorder through preservation of motion.  However, it remains controversial whether or not motion at the replaced intervertebral disc will be maintained over time.  Thus, the requested total disc arthroplasty is not likely to be more effective 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. 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 particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who had had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing provided on 8/30/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 36-year-old female enrollee has requested reimbursement for gene testing (MaterniT21 Plus) performed on 2/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  As noted by the American College of Obstetricians and Gynecologists, regardless of the method, the accuracy of screening for aneuploidy is limited in multiple gestations.  With any method based on maternal blood, only a single composite result for the entire gestation is provided, with no ability to distinguish a differential risk between fetuses.  The data regarding the performance of cell free DNA screening in twin gestations are limited.  Although preliminary findings suggest that this screening is accurate, larger prospective studies and published data are needed before this method can be recommended for multiple gestation.  Cell free DNA screening is not recommended for women with multiple gestation.  Additionally, the patient underwent testing at just over seven weeks gestation, which is earlier than recommended.  Therefore, gene testing (MaterniT21 Plus) performed on 2/03/15 was not likely to have been of greater benefit than other modalities for 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: Overturned

Summary Reviewer 3


A 51-year-old female has requested reimbursement for destruction by neurolytic agent (CPT codes 64635 and 64636) performed on 12/02/13 and 12/23/13.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This patient had both axial and radicular pain complaints.  The right lumbar medial branch nerve blocks and cooled lumbar medial branch nerve radiofrequency ablation at L3, L4, and L5 were aimed at the axial component of the back pain.  Radiofrequency ablation is a standard, widely accepted treatment for axial lumbar back pain.  Thus, the services at issue performed on 12/02/13 and 12/23/13 were likely to have been superior over other treatment alternatives.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 47-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/26/21. 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  current  guidelines  recommend  using  histopathologic  features  of  the 
melanoma  and  consideration  of  sentinel  lymph  node  biopsy  to  accurately  stage  and 
prognosticate localized cutaneous melanoma.  Gene expression profile (GEP) testing and other 
molecular testing platforms are being tested in melanoma for risk stratification, but no high level 
evidence has shown they are superior to established standards, and some data suggests they 
perform poorly in stage I disease.  Furthermore, GEP testing does not inform on treatment of 
localized, early stage disease. Therefore, DecisionDx-Melanoma testing performed on 8/26/21 
was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for the Veracyte Afirma genetic testing provided on 12/3/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule.  The physician reviewer found that Thyroid nodules are commonly managed by diagnostic fine needle aspiration to evaluate the cytopathology. In this case the finding by this standard technique was atypia of undetermined significance (Baloch, et al). This diagnostic category creates a dilemma with regards to recommended surgery. In this case, the patient was facing total thyroidectomy if malignancy was present and subtotal thyroidectomy if the lesion turned out to be benign. Hence, the sample was submitted to Veracyte for gene expression analysis. The case file has a white paper from the carrier that appears to support mutational testing. However, in a large study of over 500 patients, 6-14% of these with atypia of undetermined significance were found to have malignancy on pathology review but no mutation in several known oncogenic pathways (Nikiforov, et al). In contrast, the gene expression test done by Veracyte has demonstrated a very high negative predictive value for malignancy (Alexander, et al). All told, the Veracyte Afirma genetic testing performed on 12/3/14 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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: Overturned

Summary Reviewer  
 
The patient is a 37-year-old male who presented to his provider on 5/10/22. The patient has 
requested authorization and coverage for Stelara 90 mg/mL syringe. The physician reviewer 
found that the submitted documentation supports the medical necessity of the requested 
medication regimen. Current medical literature supports dose escalation of Stelara to 90 mg 
every four weeks in this case. The mechanism of Stelara (ustekinumab) is entirely different than 
that of anti-tumor necrosis factor (TNF) medications, which the patient has failed. Ustekinumab 
has been demonstrated to be safe and effective for induction and maintenance of remission in 
patients with moderate-to-severe Crohns disease that was resistant to anti-TNF therapy. In a 
study of patients with anti-TNF resistant Crohns disease, Kopylov and colleagues observed an 
initial clinical response to subcutaneous ustekinumab in 73.7% of the patients. The study showed 
dosing at 90 mg every four weeks was used frequently to address inadequate disease control, 
and a large proportion of patients were able to maintain response with dose escalation to 90 mg 
every four weeks. Multiple studies have shown that a majority of patients in whom Stelara dosing 
every eight weeks failed to control symptoms responded to dosing every four weeks. In this case, 
the patient has a history of severe Crohns disease diagnosed before age 30, with a history of 
stricture, fistula, and recent need for surgery. He has failed multiple biologic and conventional 
alternatives, and the records note ongoing disease symptoms while on Stelara every eight weeks. 
While a Stelara level of at least 4.5 ug/mL is associated with effective disease control, laboratory 
testing  results  noted  an  undetectable  Stelara  level  and  lack  of  anti-Stelara  antibodies. 
Continuation of dosing at every eight weeks or discontinuation of Stelara may result in loss of 
disease  control,  with  complications  such  as  fistula,  stricture,  bowel  obstruction,  flare, 
hospitalization, need for surgery, or other complications. Therefore, Stelara 90 mg/mL syringe is 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 59-year-old enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/20/20. 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 the staging and classification of cutaneous melanoma has classically been described by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma testing is an assay of 31 genes in the cells of an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. It is not known how the five-year DecisionDx-Melanoma testing data compares to the 10-year Balch data. Additionally, it is not clear if the DecisionDx-Melanoma classification can be used to make therapeutic decisions, such as whether to do a sentinel node and/or give adjuvant therapy. Therefore, DecisionDx-Melanoma testing performed on 4/20/20 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 48-year-old female enrollee has requested authorization and coverage for reconstructive lymphedema surgeries and one (1) inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrolleeas condition than any available standard therapy. The physician reviewer found that vascularized lymph node transfer is commonly performed in cancer centers to treat lymphedema. Postmastectomy lymphedema can be a difficult problem to manage. Compression therapy is the mainstay of treatment, but the medical literature indicates that microsurgical lymph node transfer or lymphaticovenous anastomosis provides better control of edema when compared to compression. Saaristo and colleagues found lymph node transfer improved lymphedema in the majority of patients and eliminated the need for physiotherapy and compression in one-third of the affected women. The authors concluded, aSimultaneous breast and lymphatic reconstruction is an ideal option for patients who suffer from lymphedema after mastectomy and axillary dissection.a Granzow and colleagues noted, aWhen applied appropriately to properly selected patients, surgical procedures used in the treatment of lymphedema are effective and safe.a The medical evidence supports the requested services in this patientas case. Therefore, reconstructive lymphedema surgeries and one (1) inpatient bed day are likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a nine-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. This patient has idiopathic short stature based on the extreme short stature, normal growth hormone test, normal insulin-like growth factor 1, poor growth velocity and absence of other etiology for short stature. The current guidelines recommend growth hormone therapy for children who have idiopathic short stature. This patient meets these criteria for treatment under the idiopathic short stature diagnosis. She is not likely to attain a normal adult height without this treatment. This patient had a poor growth velocity which greatly improved with a trial of growth hormone therapy. Therefore, Nutropin AQ Nuspin 10 is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
A  57-year-old  male  insured  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation (CPT code 64628). The Health Plan has denied this request indicating 
that the requested services are considered investigational for treatment of the insureds chronic 
low back pain. The physician reviewer found that basivertebral nerve ablation is a minimally 
invasive outpatient procedure allowing for a quick recovery. The procedure is implant-free and 
preserves  spinal  integrity  by  negating  need  for  extensive  tissue  exposure  and  disruption. 
Additionally, basivertebral nerve ablation fills a treatment gap for patients with chronic low back 
pain and preserves future treatment options. In one study, patients with chronic low back pain 
who underwent basivertebral nerve ablation reported significant improvement in pain and 
function with well documented long-term effectiveness and durability (Fischgrund, et al.). This 
patient  presents  with  more  than  six  months  of  chronic  axial  low  back  pain.  MRI  results 
demonstrated changes at disc space endplates L4-5. This patient has undergone more than six 
months of conservative treatment consisting of intradiscal steroid injection, home exercise and 
physical therapy. Gabapentin, meloxicam and methocarbamol have failed to provide sufficient 
and  durable  relief.  This  patient  does  not  warrant  more  invasive  treatment,  such  as 
decompression and fusions, as there are no reported severe symptoms of lumbar radiculopathy. 
Given these findings the requested intraosseous basivertebral nerve ablation (CPT code 64628) 
is likely to be more beneficial than any other available standard treatments for the patients 
medical condition.