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

Summary Reviewer 2

A 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that there is a lack of evidence based literature that show the efficacy of genetic testing in evaluating patients  diagnosed with bipolar disorders or ADHD. There is very limited clinical justification, based on substantial medical research, to endorse genetic screening tests prior to attempting another medication for treatment of ADHD, bipolar disorder, or personality disorders.  Specifically, the standard of care for treatment of these disorders would be to continue to trial or prescribe stimulant medication. This method of prescribing medication would produce similar outcomes when compared to awaiting genetic testing results in this patients case.  In sum, cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and SNP variants for chromosomal abnormalities administered on 3/16/16 were not likely to have been more effective than the standard options available for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been 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

The parent of a 13-year-old male enrollee has requested reimbursement for balloon sinus ostial dilation performed on 10/28/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic sinus problems. The physician reviewer found there is a lack of support for the services at issue in this patients case.  The records noted that the patient had evidence of PANDAS.  This problem was ultimately treated with removal of tonsils and adenoids in July 2015.  The patient apparently had some evidence of nasal and sinus congestion and difficulty breathing through the nose, but there is no mention of adequate medical management of the sinus congestion prior to consideration of any surgical intervention such as inferior turbinate ablation and balloon sinus dilation technology.  Preoperative computed tomography (CT) scan demonstrated that the maxillary, ethmoid and frontal sinuses showed some degree of mild mucus congestion, but there was no evidence of any severe thickening or obstruction of the drainage pathways of the paranasal sinuses. At present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management is still considered the surgical treatment of choice. Thus, balloon sinus ostial dilation performed on 10/28/15 was not likely to have been of greater benefit than other treatment alternatives. 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 seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, eight hours per month of supervision and six hours for the contract period for re-assessment provided from 11/9/16 through 5/9/17. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the correlation between treatment outcomes and treatment intensity is well documented. Ample research has shown that intensive applied behavior analysis (ABA) treatment produces robust outcomes for individuals with autism spectrum disorder (ASD). (Linstead, et al). Linstead and colleagues studied 726 children (ages 1.5 to 12) to evaluate the relationship between treatment intensity and treatment outcomes. The study showed a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. In this case, the patient continues to demonstrate significant delays that place him at an increased risk for injury, and also makes it difficult for him to be successful in more generalized environments. Based on the documentation submitted for review, the request for 40 hours per week of direct ABA therapy, eight hours per month of supervision and six hours for the contract period for re-assessment provided from 11/9/16 through 5/9/17 were and are medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 26-year-old female enrollee has requested reimbursement for laboratory services (CPT code 83993) performed on 10/5/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees structuring ileocolic Crohns disease. The physician reviewer found that persistent disease activity is associated with a poor prognosis in inflammatory bowel disease (IBD). Therefore, monitoring of patients in this clinical setting with intent to suppress subclinical inflammation has emerged as a reasonable community standard treatment goal. As endoscopic monitoring is invasive and resource intensive, identification of valid markers of disease activity has been a priority. Calprotectin, when measured in feces, is now used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify IBD. Fecal calprotectin may also be useful, as has been proposed for this patient, to monitor patients with IBD under treatment and to predict the risk of recurrence of active disease prior to clinical relapse (Burri and Beglinger). Given this support, the laboratory services (CPT code 83993) performed on 10/5/17 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 29-year-old female enrollee has requested reimbursement for chiropractic care provided from 1/30/19 through 6/28/19 and physical therapy provided from 5/06/19 through 6/06/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient underwent physical therapy and chiropractic care after her motor vehicle accident in November 2018. She had persistent symptoms despite the physical therapy and chiropractic services that were rendered. She did not have any impairment that would have precluded her from performing an independent exercise and palliative modality program after a short series of visits to physical therapy following the motor vehicle accident. There was no indication of objective benefit of ongoing chiropractic therapy. While the patient may have had ongoing symptoms, her symptoms would not have been expected to marginally improve with the interventions in question over an independent program. In fact, despite the interventions that were rendered, no significant objective benefit that can be reasonably attributed to the services in question is documented. Therefore, chiropractic care provided from 1/30/19 through 6/28/19 and physical therapy provided from 5/06/19 through 6/06/19 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 64-year-old female with severe obstructive sleep apnea. The medical records document a history of unsuccessful attempts to utilize the gold standard treatment of continuous positive airway pressure (CPAP) therapy. On 9/12/17, the records noted a body mass index of 20.2. On 9/26/17, septoplasty and bilateral inferior turbinate reduction was performed. On 10/12/17, a home sleep study confirmed that the patient had a total of 162 obstructive apnea episodes, without central apnea. The documentation noted an apnea-hypopnea index of 43.0 episodes per hour of sleep. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  There is sufficient support for the requested device in this clinical setting. This patient meets clinical criteria for consideration of surgical management of her obstructive sleep apnea symptoms. Prior evaluation has documented the degree of obstructive sleep apnea to be severe. The patient had trialed CPAP therapy for airway management and was intolerant to the use of this device. Clinical studies indicate that patients only benefit from this device when they have a body mass index less than 32, and the patient meets this criteria. Per the medical evidence, patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of this disorder. All told, the requested implanted nerve stimulator is likely to be superior over other available treatment options. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer
 
The patient is a 37-year-old female with a history of mood and psychotic disorder and borderline personality disorder. The patient was admitted to a residential treatment center (RTC) three weeks after she reportedly overdosed on Ativan. She was admitted to the RTC on 12/29/15. The patient was treated with psychotherapy, milieu therapy, and psychopharmacology with Geodon and lithium. The patient has requested reimbursement for RTC services provided from 1/15/16 through 2/11/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. Based on the Level of Care Utilization System (LOCUS) criteria, an accepted, national standard for determining the appropriate level of care for adults, the patient demonstrated moderate risk of harm (score 3) given a suicide attempt three weeks prior to her admission at the RTC.  However, the patient had some improvement in the RTC and did not have any suicidal or homicidal ideation by 1/15/16. The patient had moderate functional impairment (score 3) with a serious deterioration in her ability to fulfill her responsibilities. She has ongoing severe interpersonal deficits. The patient has made progress while she has been in the RTC. Documentation by 1/15/16 states that the patient had improved insight, was more self-aware, was more engaged, and her psychotic symptoms were resolving. The patient had significant co-morbidity (score 3) with a mood and psychotic disorder as well as borderline personality disorder. The patients recovery environment was moderately stressful (score 3) as she broke up with her boyfriend four months prior to entering the RTC and this was seen as a major transition for the patient. The patient had limited support from others (score 3) and she demonstrated equivocal response to treatment and recovery (score 3) as she had been treated in an outpatient settings prior to her admission. The patient demonstrated limited engagement and recovery (score 3) as she was attentive and engaged during treatment. However, the patient was guarded and would not share her entire inner-experience. Documentation states that the patient showed more self-awareness and has been more engaged in groups. This gives the patient a composite score of 21, which is consistent with partial hospitalization program (PHP). The patient required treatment for her mood and psychotic disorder and borderline personality disorder, but this could have been done at a PHP level of care. Therefore, the RTC services provided from 1/15/16 through 2/11/16 was 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: Upheld

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for homocysteine testing and polymerase chain reaction testing for EBV performed on 8/08/18. 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 the evaluation for vitamin B12 deficiency includes an examination for gastrointestinal, dermatologic, neurologic, and other findings, and laboratory testing, including a complete blood count and vitamin B12 levels. Additional testing with methylmalonic acid (MMA) or homocysteine levels may be appropriate if the vitamin B12 level is borderline low or discordant with the clinical picture. In this case, do not support the need for homocysteine testing. Therefore, homocysteine testing and polymerase chain reaction testing for Epstein Barr virus performed on 8/08/18 were not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. 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 for patients with localized endometrial cancer, if the patient has elevated CA-125 at the time of initial diagnosis, then current National Comprehensive Cancer Network guidelines recommend serial testing of serum CA-125 for recurrence monitoring.  Multiple other serum proteins expressed by endometrial cancer are currently being investigated as possible markers for recurrent disease, including human epididymis protein 4 (HE4). Secreted HE4 has been extensively studied as a serum biomarker for proposed uses for either screening, detection of recurrence or monitoring of therapeutic response for ovarian cancer. Secreted HE4 is also associated with endometrial cancer, and continues to be studied as a potential biomarker for differentiating between malignant and benign pelvic masses, screening for malignancy, prognosis, recurrence detection, and therapeutic response. However, it is not currently accepted as a standard of care for patients with endometrial cancer. The study by Abbink and colleagues compared HE4 to the standard of care marker CA-125. Although the authors indicated the possibility of superior performance of HE4 compared to CA-125 for detection of recurrence in patients with endometrial cancer, they also noted that a future prospective study on a larger cohort of patients with endometrial cancer is needed to affirm the preoperative value of serum HE4 and the use of HE4 in routine follow-up. At this time, the superior efficacy of the services at issue has not been established. Thus, HE4 testing performed on 9/20/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 50-year-old male has requested authorization and coverage for code 43210 and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the efficacy of transoral incisionless fundoplication (TIF) using the EsophyX device has been studied in randomized controlled trials. However, the conclusions are contradictory. The large randomized trial by Witteman and colleagues included 60 patients. The authors found no improvement in esophageal acid exposure compared with baseline at 12 months. Normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of proton pump inhibitors in 61%. The study concluded that no long-term objective reflux control was achieved. A recent meta-analysis by McCarty and colleagues noted that further safety and efficacy comparison is needed with conventional treatment, such as Nissen fundoplication. There have been reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. Thus, code 43210 and one inpatient bed day are not likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the molecular pathology testing provided on 4/14/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers (Brose, et al; Thompson and Easton). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers (Liede, et al; Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed (Umar, et al). However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extracolonic tumors in Lynch syndrome are endometrial, ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral cancers. This patients family history is suggestive of a breast/ovarian cancer syndrome. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Therefore, the testing at issue 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: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 29-year-old female who presented to her provider for prenatal care at a gestational age of 22 weeks. At 18 to 20 weeks gestation, a screening anatomy scan was performed and a thickened nuchal fold was noted. This was again confirmed on a follow up ultrasound and a subsequent recommendation for chromosomal testing was offered. The provider discussed the option of amniocentesis or cell free DNA screening. The patient had opted for cell free DNA screening. The patient has requested reimbursement for fetal chromosomal aneuploidy genomic sequence performed on 9/18/17. The Health Insurer denied reimbursement and reported that the services at issue were not medically necessary for the evaluation of this patients medical condition. There is support for the medical necessity of the services at issue in this clinical setting. The American College of Obstetrics and Gynecology (ACOG) in conjunction with the Society for Maternal Fetal Medicine addressed the issue of the use of cell free DNA testing. The Committee Opinion recognized patient option to choose noninvasive prenatal testing as a strategy to screen for aneuploidy regardless of the patients risk status but does so with the caveat that she understands the limitations and benefits of this screening paradigm in the context of alternate screening and diagnostic options. Essentially, ACOG Committee has defined testing as it relates to low risk and high risk patients. In this case, the patient met the criteria for high risk setting due to a thickened nuchal fold that was noted by a screening anatomy scan at 18 to 20 weeks gestation and again confirmed on a follow up ultrasound. This finding, although isolated, is associated with an increased risk of aneuploidy specifically Trisomy 21. Nuchal edema or fold which is measured at more than 6 mm is found in about 0.1 to 0.5% of fetuses. It may be of no pathological significance; however, these findings may be associated with chromosomal defects, cardiac anomalies, infection or genetic syndromes. The measurement is considered abnormal if it is 6 mm or greater.  In this case, the patients nuchal edema or fold was 6.4 and was elevated for all gestational ages between 15 to 24 weeks. Using a threshold of 6 mm, or greater, as an abnormal measurement, 40% of the fetuses with trisomy 21 were identified with a thickened nuchal fold. A thickened nuchal fold is also associated with euploid syndromes, such as the Noonan syndrome, as well as with heart defects. In sum, the fetal chromosomal aneuploidy genomic sequence performed on 9/18/17 was medically necessary for the evaluation of this patient.Therefore, for the reasons stated above, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.