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

Summary Reviewer 2 
 
A 19-year-old male enrollee has requested authorization and coverage for lumbar disc 
arthroplasty and two inpatient days. 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 the medical evidence does not support the 
requested services in this clinical setting. This patient has a large disc protrusion causing severe 
central canal and right lateral recess stenosis, with no prior surgeries. The most straightforward 
and lowest risk operation indicated is for a posterior decompression procedure (lumbar  laminotomy versus laminectomy and a microdiscectomy). A lumbar arthroplasty is not 
indicated as the initial operation for a disc herniation causing central and lateral recess stenosis. 
Central stenosis and lateral recess stenosis, resulting in single nerve root compression, are 
listed as contraindications to lumbar disc arthroplasty in the published literature according to 
the referenced U.S. Food and Drug Administration (FDA) ProDisc patient insert. Therefore, the 
requested lumbar disc arthroplasty and two inpatient days are not likely to be more beneficial 
than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that Ttansanal hemorrhoidal dearterialization is an option for the treatment of grade II and III internal hemorrhoids in patients that have failed non operative treatment. However, randomized trials have failed to consistently demonstrate significant benefits of this therapy alternative surgical procedures. Although there is data to show that transanal hemorrhoidal dearterialization is a safe and effective method of surgically treating hemorrhoids, there is a lack of clinical trials reporting benefits of transanal hemorrhoidal dearterialization over standard treatment options. Thus, the Doppler guided transanal hemorrhoidal dearterialization provided on 11/20/17 was 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 services at issue were 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 


An 18-year-old male enrollee has requested reimbursement for mental health intensive outpatient program (IOP) services provided from 12/16/15 through 1/18/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. The documentation submitted for review supports placement at the IOP level of care. Tamez and colleagues report on the benefits of treating depression in IOP programs particularly if the patient does not require acute hospitalization, but requires additional supportive services prior to fully reintegrating back into the community. In this case, the patient has a history of depression, OCD with prior suicide attempts one of which was serious as the only reason for its failing was the failure of the apparatus. Per the individual session note dated 1/8/16 the patient reported to being very depressed and feeling alone. During the dates in dispute the patient required continued supportive services with individual, family and group therapies prior to discharge into the community. Accordingly, IOP services provided from 12/16/15 through 1/18/16 were medically necessary for treatment of the patients behavioral health condition. 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the patient has had a history of enlarged lymph nodes of unknown etiology. She has had a biopsy and blood tests, which were all negative. She had a PCR test Epstein-Barr virus and other organisms. The common testing performed for lymphadenopathy can generally determine the cause of the lymphadenopathy. The test results for this patient were normal but she continued to have large lymph nodes. A PCR test to detect the cause of the lymphadenopathy is within the standard of care to evaluate uncommon etiologies of large lymph nodes such as in this patients case when all standard first step work up have been negative. As such, PCR testing provided on 5/30/17 was likely to have been more effective than the available standard techniques for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 26-year-old male enrollee has requested authorization and coverage for the LINX reflux management system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).   The physician reviewer found there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. One evidence-based review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al).  A peer-reviewed journal published a letter stating that there are 11 reports of endoscopically-confirmed LINX erosion through the esophagus in the FDA database (Bielefeldt, et al).  Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention, which is a concern in this patient (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial in this case than standard treatment, surgical fundoplication (Sheu, et al). American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Therefore, according to current literature and clinical guidelines, LINX is not likely to be more efficacious for treatment of GERD and should be considered investigational.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 61-year-old female enrollee has requested authorization and coverage for Viekira Pak. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  It is advantageous to treat patients before they progress to cirrhosis.  Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Viekira Pak is medically indicated for the treatment of this patient.  Therefore, 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

A 43-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/8/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that the patient is a 43-year-old asymptomatic female who was evaluated with screening mammogram and digital breast tomosynthesis on 8/8/16. This study revealed no evidence of malignancy. The Health Insurer has denied reimbursement of digital breast tomosynthesis performed on 8/8/16. Per the Health Insurer, the service at issue was investigational for the evaluation of this patient. There is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis, to the usual two dimensional protocol on 8/8/16 was likely to be more effective than had the patients examination been performed using two dimensional imaging alone. 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested authorization and coverage for ketamine infusion and one day inpatient stay. The Health Insurer has denied this request indicating that the requested services are considered experimental/investigational for treatment of the enrollees peripheral neuropathy status post chemotherapy treatment. The physician reviewer found the requested services are not likely to be more effective for this patient than other available treatment options. The medical records provided for review report a condition of chronic pain with diagnosis of small fiber neuropathy (biopsy proven) with a history of chemotherapy for breast cancer.  The medical records also report complex regional pain syndrome (CRPS), but the documentation submitted for review does not detail specific information in support of this diagnosis. The medical records report failure of interventional, physical and psychological modalities, but the documentation does not detail the particular treatments or duration of those treatments in support that all standard treatments have not helped. Kosharskyy and colleagues note that ketamine infusions may have benefit for CRPS; however there is insufficient evidence in regards to neuropathy related pain.  In addition, there is a lack of medical literature of standardized dosing regimen or duration of such therapy in regard to peripheral neuropathy/small fiber neuropathy pain.  All told, the peer reviewed literature does not support ketamine infusion as likely to be more beneficial for treatment of the patients medical condition than other modalities for the treatment of peripheral neuropathy related pain. 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 a 56-year-old male who presented to his provider on 1/6/22. The patient has 
requested authorization and coverage for aprepitant 80 mg. The physician reviewer found that 
at issue is whether aprepitant 80 mg is medically necessary for the treatment of this patient. The 
submitted documentation supports the medical necessity of the requested medication. Pruritus 
occurs in the majority of patients with polycythemia vera and is often exacerbated by bathing,  
especially with hot water, which results in aquagenic pruritus. Symptom management begins 
with simple measures such as avoidance of precipitating exposures such as paying attention to 
the temperature of the environment and the water used for bathing, adding laundry starch to 
bath water, drying the skin by patting rather than rubbing, and using moisturizing creams and 
antihistamines.  Low-dose  aspirin  is  generally  effective  for  alleviating  pruritus  and  other 
symptoms associated with polycythemia vera. Among cytoreductive agents, the most effective 
agent for pruritus associated with polycythemia vera is ruxolitinib, which this patient is already 
on. He and colleagues report that aprepitant has demonstrated effectiveness in several case 
series  and  open  label  trials  in  relieving  pruritus  for  patients  who  are  refractory  to  other 
treatments. Current medical literature supports the benefits of aprepitant in the setting of 
pruritus related to hematologic malignancies including T-cell lymphomas, polycythemia vera, and 
other malignancies. In this clinical setting, given that the patient has tried and failed several 
measures and medications for the treatment of debilitating aquagenic pruritus, and reports 
benefits from aprepitant 80 mg, the requested medication is medically indicated. Therefore, 
aprepitant 80 mg is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 55-year-old female enrollee has requested reimbursement for CPT code 95165, professional services for the supervision and provision of antigens for allergen immunotherapy provided from 2/10/15 through 2/13/15. 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 the submitted letters from the patient and provider were reviewed.  However, there is a lack of additional pertinent medical documentations, such as progress notes from the ordering provider.  The progress notes submitted are from a different provider which documented the diagnosis of mast cell disorder, chemical sensitivities and food allergy.  The only records from the ordering provider were testing records, which are insufficient to support the services at issue.  The submitted records do not support a covered indication for the services at issue.  Based upon the information set forth above, the services at issue were 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 parent of a 17-year-old male enrollee has requested authorization and coverage for Dupixent (dupilumab) 300/2 ml injections. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. The medical records document longstanding atopic dermatitis which has been recalcitrant to treatment with topical steroids, topical calcineurin inhibitors, prednisone and cyclosporine.  Dupixent has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe atopic dermatitis in patients aged 12 years and older. This patients condition has been poorly controlled with topical and systemic immunosuppressants. He has had side effects from cyclosporine, necessitating discontinuation. Therefore, Dupixent (dupilumab) injections 300/2 ml are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found according to the documentation submitted for review, the patient presented with symptomatic chronic atrial fibrillation that failed aggressive attempts to manage his condition medically. The guidelines listed above support the use of catheter-based ablation (radio frequency or cryoablation) for management of patients in this clinical setting. For the reasons provided above, the services at issue were 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 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 2 
 
A 24-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/06/21. 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 melanoma is a cancer that is curable in its earliest stages. Cutaneous 
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for 
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha.  The data on the 
DecisionDx-Melanoma has not made it part of routine analysis after sentinel lymph node biopsy. 
There has also been some lack of consistency between various genes being used as biomarkers. 
As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm 
beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 
7/06/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 65-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 6/13/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found that breast tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration in 2011. Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  The use of this technique often allows the reader to separate dense glandular elements from underlying architectural distortion and mass, which in turn improves diagnostic accuracy, reduces callbacks and reduces negative biopsies. The medical evidence supports the service at issue in this clinical setting. Therefore, breast tomosynthesis performed on 6/13/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 28-year-old male enrollee has requested reimbursement for Foundation One gene test performed on 4/7/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with malignant peripheral nerve sheath tumor (MPNST). The physician reviewer found that the malignant peripheral nerve sheath tumors (MPNST) are an uncommon but devastating tumor of peripheral nerve. About 22 to 50 percent of MPNSTs occur in patients with neurofibromatosis type 1 (NF1). Having a NF1 mutation adds information for prognosis and aids in follow-up decision making. FoundationOne offers the advantage of testing for NF1 mutations as well as others that may help guide therapeutic decision making should the patient progress. FoundationOne testing is likely to be more beneficial than not testing and not knowing the prognosis of the patient. In sum, FoundationOne testing performed on 4/7/15 was likely to have been more effective over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 51-year-old male with gastroesophageal reflux disease (GERD). Per the providers note dated 4/9/15, the patients symptoms include reflux, heartburn, emesis, and dysphagia. Esophageal manometry showed no classic abnormalities of esophageal motility or bolus transit on 3/9/15. A pH study with impedance showed elevated acid exposure, particularly when recumbent, and significant upright reflux with strong symptom correlation on 3/9/15. Per the provider, proton pump inhibitors have not been effective, and consistent and prolonged exposure to chronic acid due to uncontrolled GERD presents the possibility of progression to Barretts esophagus, which is considered a premalignant condition to esophageal adenocarcinoma. The patient has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. Overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al; Ganz). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX device 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 requested procedure 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.