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

Summary Reviewer 

A 59-year-old female enrollee has requested reimbursement for Avastin provided from 5/27/15 through 8/4/15. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollees metastatic colorectal carcinoma. The physician reviewer found that in this case, chemotherapy is being used in the neoadjuvant setting. There is limited data on neoadjuvant chemotherapy since most patients in this clinical setting typically present with inoperable advanced disease. Neoadjuvant treatment is a medically reasonable approach in a patient with limited stage disease that is potentially operable (Assifi, et al; Andriulli, et al). The best chemotherapy options include gemcitabine or oxaliplatin or cisplatin combined with fluoropyrimidines, gemcitabine with Abraxane, gemcitabine with erlotinib, and gemcitabine with docetaxel and capecitabine (Ghosn, et al). In addition, Avastin did improve progression-free survival when combined with erlotinib and gemcitabine (Van Cutsem, et al). All told, there is adequate data supporting the medical necessity of the Avastin provided to this patient from 5/27/15 through 8/4/15. 
Consistent with these findings, the medication at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 13-year-old male who has been evaluated by a pediatric endocrinologist since 2014. In 2014, he displayed normal growth velocity and delayed bone age.  The patients parent has requested authorization and coverage for Humatrope injection 24 mg. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the U.S. Food and Drug Administration (FDA) defines idiopathic short statute as height z-score below 2.25 standard deviations without apparent etiology after thorough professional evaluation. This patient does not meet these criteria. His growth velocity and provoked growth hormone release are normal. His growth pattern and predicted adult height are consistent with his familial pattern. His predicted adult height of 66.5-67 is within the normal range for adult men in North America. This patient not meet clinical criteria for an FDA-approved indication for somatotropin.  Familial short stature with constitutional delay of growth and development is the most appropriate diagnosis as documented by the treating pediatric endocrinologist. Therefore, Humatrope injection 24 mg is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 4/4/15 through 6/10/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder, recurrent. The physician reviewer found that the submitted records from 4/4/15 through 6/10/15 fail to support the need for RTC level of care for treatment of this patients medical condition. The notes that were submitted contain little or no information about the patients behaviors or mental status. In addition, there is no documentation of any problem behaviors or medical problems. The patients history explained his lack of cooperation with therapy prior to admission. However, there was no stated reason for continuation of treatment as of 4/4/15. All told, the RTC services provided from 4/4/15 through 6/10/15 were not medically necessary for treatment of this patients behavioral health issues. 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 2

A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that topical sirolimus offers superior benefit for the control and resolution of angiofibromas in tuberous sclerosis complex. There is robust evidence supporting the efficacy and safety of topical sirolimus, which targets the etiology of this rare genetic disorder. The alternative therapies of hyfrecation, shave removal or laser ablation all carry risks of permanent scarring and are less effective than topical sirolimus. All told, sirolimus cream is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 60-year-old female with a history of hypertension, coronary artery disease with angina and anxiety who was admitted to the hospital at an inpatient level of care on 2/15/19 with a diagnosis of intractable left hip pain and left lower extremity pain. The patient has requested reimbursement for inpatient stay at Glendale Memorial Hospital from 2/15/19 through 2/20/19. The Health Plan has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that most people with acute or subacute musculoskeletal pain will improve over time regardless of treatment. Per Qaseem and colleagues, clinicians and patients should select non-pharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation over pharmacologic intervention. The authors noted, aIf pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants.a Patients with chronic pain are recommended to participate in rehabilitation, exercise and other non-pharmacologic modalities. Per the authors, if pharmacologic therapy is indicated, then treatment with nonsteroidal anti-inflammatory drugs are a first-line therapy, or tramadol or duloxetine as a second-line therapy for chronic pain. In this patientas case, the inpatient admission was not medically necessary. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. At the time of admission, she was hemodynamically stable without any physical findings or symptoms concerning for a neurologic emergency, such as cauda equina syndrome. She was able to void and ambulate with assistance from her husband. She required pharmacologic treatment of acute pain in the hip and low back, but her pain improved with treatment.  Her cardiac status remained stable, without any evidence of acute coronary syndrome.  She was discharged home with plans for outpatient physical therapy. Therefore, inpatient stay at Glendale Memorial Hospital from 2/15/19 through 2/20/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 57-year-old female enrollee has requested authorization and coverage for (azithromycin) Zithromax. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found Zithromax is used to treat many different types of infections caused by bacteria, such as respiratory infections, skin infections, ear infections, and sexually transmitted diseases. The documentation submitted for review does not support these indications for use of Zithromax in this patients case. Moreover, there is a lack of medical literature for the use of Zithromax in gastrointestinal disease. The medical literature available for the use of Zithromax in gastrointestinal disease was for Parkinsons disease associated with gastroparesis and small bowel bacterial overgrowth, neither of which has been documented in the patients clinical documentation.  For the reasons provided, the patients request for (azithromycin) Zithromax has not been established as medically necessary. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 20-year-old male with a history of urinary frequency, urgency, and nocturia. The patient has been treated with Ditropan, which was discontinued for constipation, and Myrbetriq, which provided minimal symptomatic improvement. The patient underwent the first of 12 scheduled percutaneous tibial nerve stimulation (PTNS) sessions on 10/16/17. The patient has requested reimbursement for PTNS provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. PTNS is considered third-line therapy in the current medical literature. The use of physical therapy or physical therapy combined with medication has been demonstrated to be more efficacious in the peer-reviewed medical literature. PTNS may be indicated in lieu of more invasive neuromodulation therapy to avoid implantable sacral nerve modulation in well selected patients. However, there is a lack of support for treatment with PTNS for this patient given the available standard therapies. All told, the PTNS provided on 10/16/17 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 service at issue was 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 

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for IVIG (Octagam) from 4/29/16 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 enrollee, who has symptoms of distal sensory paresthesias, fatigue and weakness in the lower extremities. The physician reviewer found that the medical literature support the services at issue in this clinical setting. Although IVIG is not indicated for all cases of neuropathy, it is indicated for patients diagnosed with CIDP and in some cases, those patients with autoimmune disease.  In this particular case, the patient carries the diagnosis of CIDP and has had a reported benefit of her clinical symptoms in response to this therapy.  The medical literature demonstrates the benefit of IVIG in patients with CIDP. To undertreat an autoimmune neuropathy would place the patient at risk of significant clinical decline and functional impairment.  In this patients case, the continued use of IVIG is medically indicated, given her medical history. As such, IVIG (Octagam) from 4/29/16 forward was and is medically necessary. Therefore, for the reasons stated above, 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that in the medical literature, Jadvar and colleagues reported that in patients with relapsed prostate cancer, 18F-NaF PET/CT is useful in the detection of occult osseous metastases, whereas the yield of 18F-FDG PET/CT is relatively limited. Poulsen and colleagues found that 18F-NaF PET/CT were superior to whole body scintigraphy with regard to detection of prostate cancer bone metastases within the spine. Thus, the literature does support 18F-NaF PET/CT to be superior to bone scan with regards to detection of prostate cancer bone metastases within the spine. Further, the requested 18F-NaF PET/CT is the most reliable tool when there is high index of suspicion for osseous metastases. Consistent with this support, the requested 18F-NaF PET/CT scan is 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 requested diagnostic procedure is 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 3


A 60-year-old male enrollee has requested reimbursement for the fecal calprotectin testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees Crohns disease.   The physician reviewer found fecal calprotectin has commonly been used practice given the multiple studies showing its beneficial effect and accuracy. Since the patients calprotectin was low, the provider focused his attention on a different diagnosis than Crohns flare, thus sparing additional, and more invasive testing that would not have been beneficial. Based on clinical utility that has been documented in multiple clinical trials, the fecal calprotectin testing performed on 11/17/15 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, the testing 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 57-year-old female insured has requested reimbursement for a blood test performed on 
3/7/23. The Health Insurer has denied this request indicating that the service at issue was 
considered investigational for the evaluation of the insureds rheumatoid arthritis. The physician 
reviewer found that there are a lack of established medical trials comparing the use and efficacy 
of the Vectra DA blood test with standard clinical disease activity assessments, including the DAS 
28-CRP, for patients with rheumatoid arthritis. Further study is required to validate the efficacy 
of multi-biomarker blood tests. The National Institute for Health and Care Excellence (NICE) 
recommends monthly monitoring of C-reactive protein and disease activity until remission or low 
disease activity, measured by DAS 28 scoring. NICE does not mention biomarker tests in its 
recommendations. Overall, there is insufficient evidence to support the use of multi-biomarker 
blood tests such as the Vectra DA blood test for the evaluation of this patients rheumatoid 
arthritis. Given these findings, the blood test performed on 3/7/23 was not likely to have been 
more beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 51-year-old male who presented to his provider on 5/11/21 for evaluation of chronic low back pain with associated acute bilateral L5-S1 radiculopathy. The patient has requested authorization and coverage for MRI of the lumbar spine. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. According to the American College of Radiology, if lower back pain persists after four to six weeks of conservative management, and the patient is a surgical or intervention candidate, then MRI of the lumbar spine is the usually appropriate next exam. This patient presented with low back pain with associated radiculopathy symptoms. He failed conservative management in the past per the patientas provider, including physical therapy. Therefore, MRI of the lumbar spine is an appropriate exam and could change the patientas management, which may include surgical intervention or interventions such as pain management. Therefore, the requested MRI of the lumbar spine is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 66-year-old male enrollee has requested authorization and coverage for Viagra 100mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees erectile dysfunction The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Both Viagra and Levitra are phosphodiesterase inhibitors which are used to treat erectile dysfunction.  Per the medical evidence, both drugs have a similar mechanism of action and pharmacokinetics.  The current medical literature does not support significant differences in efficacy between the two medications.  In this patients case, treatment with Levitra is medically appropriate.  All told, Viagra 100mg tablets are not medically indicated for the treatment of this patient.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be 
upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 28-year-old male enrollee has requested reimbursement for ColonSentry testing (CPT code 81479) performed on 10/23/14.  The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found the review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. Serum biomarkers for colon cancer screening are not recommended by the National Comprehensive Cancer Network (NCCN) guidelines for colorectal cancer (CRC) screening (Provenzale, et al). According to Fletcher The New York State Department of Health also approved a seven-gene test (ColonSentry) in February 2012 to be used to identify patients at increased risk of colorectal cancer in order to target such patients for monitoring to assure compliance with regular colonoscopy. However, it has not been shown that the test can detect early-stage cancers, for which screening would be most effective, and test sensitivity (61 to 82 percent) and specificity (64 to 77 percent) were only fair for CRC at any stage when tested in populations that included a substantial proportion of patients with known CRC. Based on the lack of support in the peer-reviewed literature, the ColonSentry testing (CPT code 81479) performed on 10/23/14 was not likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. This patient has not exhausted all other possible therapies for rheumatoid arthritis, and the medical records do not clearly document that the patient has failed each therapy reported to have been tried and failed. Acthar Gel has not been proven to be superior to alternative therapies, such as prednisone or methylprednisolone, in terms of efficacy or safety for the long-term management of rheumatoid arthritis. Since Acthar Gel exerts at least some of its anti-inflammatory effects through corticotrophin receptors, Acthar Gel carries the same potential risks as steroids, including diabetes. 
H.P. Acthar has a corticotropin effect and with that, the same potential side effect profile as steroids with respect to osteoporosis, glaucoma, cataracts, weight gain, increased blood pressure, and glucose intolerance. Therefore, corticotropin (Acthar Gel) is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, her breasts have been described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis performed on 3/22/16 was likely to have been of greater benefit than other modalities for 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