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

Summary Reviewer  
The patient is a two-year-old male who presented for his two-year checkup on 7/11/22. The 
patients parent has requested authorization and coverage for Synagis 100 mg/mL every 28 days 
x  five  months.  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 submitted documentation 
does not support the medical necessity of the requested medication. The Committee on Infectious 
Disease  and  American  Academy  of  Pediatrics  recommend  the  use  of  palivizumab  for  the 
administration of prophylaxis for the following groups of patients: preterm infants with chronic 
lung disease (CLD) born at less than 32 weeks of gestation requiring supplemental oxygen for at 
least the first 28 days of life, with consideration for a second year of prophylaxis if ongoing medical 
support is required for CLD; children with hemodynamically significant congenital heart disease 
(CHD) in their first respiratory syncytial virus (RSV) season, including those with acyanotic heart 
disease receiving medication to control congestive heart failure and who will require surgical 
intervention and those with moderate to severe pulmonary hypertension; infants with cyanotic 
heart disease in their first RSV season in consultation with their cardiologist; infants with CHD 
that receive RSV prophylaxis following surgical procedures requiring cardiopulmonary bypass, 
due to a decrease in palivizumab serum concentration; children less than two years of age that 
undergo cardiac transplantation during an RSV season; preterm infants born before 29 weeks of 
gestation; infants with neuromuscular disease or congenital anomaly that impairs airway clearance; 
children younger than 24 months that will be profoundly immunocompromised during the relevant 
RSV season; and infants with cystic fibrosis complicated by CLD and/or nutritional compromise 
for their first RSV season, and for a second season in the presence of severe lung disease. 
Palivizumab prophylaxis is not recommended for any children over the age of 24 months. There 
is lack of medical literature supporting its use or efficacy in this population. Luna and colleagues 
report that expert consensus on palivizumab use for RSV recommends palivizumab for preterm 
infants, former preterm children aged at or less than 24 months with CLD/bronchopulmonary 
dysplasia, children aged at or less than 24 months with significant CHD, and other high-risk 
populations,  such  as  children  aged  at  or  less  than  24  months  with  Down  syndrome, 
pulmonary/neuromuscular  disorders,  immunocompromised,  and  cystic  fibrosis.  Given  that 
palivizumab prophylaxis is not recommended in children over the age of 24 months, the requested 
medication is not medically indicated. Therefore, Synagis 100 mg/mL every 28 days x five months 
is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for HCMNext Reflex-Ambry genetic test performed on 10/2/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollee, who has a history of hypertrophic cardiomyopathy. The physician reviewer found that this patient has clinical features suggesting hypertrophic cardiomyopathy, a genetic disease that may lead to heart failure or sudden cardiac death. She had left ventricular septal hypertrophy by echocardiogram and a family history of sudden cardiac death. Based on current Heart Rhythm Society (HRS) and the European Heart Rhythm Association (EHRA) guidelines, genetic testing is recommended ( a class I indication) for any patient in whom a cardiologist has established a clinical diagnosis of hypertrophic cardiomyopathy based on the patients clinical history, family history and EKG/ECHO phenotype. This patient meets these guideline criteria. Genetic testing was medically indicated and confirmed the diagnosis. As such, the genetic testing at issue was within standard of care. Therefore, HCMNext Reflex-Ambry genetic test performed on 10/2/17 was likely to have been more efficacious than the available modalities for evaluating this patients medical condition.

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: Overturned

Summary Reviewer 2

A 41-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) provided from 10/02/20 through 11/20/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient has failed multiple medication trials and continues to have depressive symptoms. He had experienced a positive response to TMS in the past, with an over 50% reduction in symptoms during that time. TMS is currently approved for treating patients who are suffering from the acute phase of major depressive disorder. Given that this patient was still experiencing an acute episode, the medical evidence supports continued treatment. Therefore, TMS provided from 10/02/20 through 11/20/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 25-year-old female enrollee has requested authorization and coverage for breast reduction surgery.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that this patient has evidence of significant symptomatic macromastia.  This is noted to affect her activities of daily living with exercise.  Her stated symptoms include neck, back and shoulder pain, shoulder grooving and scarring from periodic ulcerations.  Her photographs are supportive that her clinical condition and functional deficits are likely directly related to her macromastia.  There is sufficient support for the requested services in this patients case.  Specifically, a 400 gram reduction is considered a significant reduction for a patient who is this size.  In addition, she has failed conservative management.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  In this patients case, breast reduction is standard of care.  In sum, the requested breast reduction surgery is medically indicated for the treatment of this patient.  Therefore, the requested services 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 51-year-old female enrollee has requested authorization and coverage for 64628  thermal 
destruction of intraosseous basivertebral nerve. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees low back 
pain. At issue is whether 64628  thermal destruction of intraosseous basivertebral nerve is likely 
to be more beneficial for treatment of the enrollee's condition than any available standard therapy. 
The physician reviewer found that chronic low back pain is a debilitating condition. When Modic 
changes are present in the disc spaces, a vertebrogenic cause of back pain is considered an etiology 
of chronic back pain. The main source of innervation for the vertebral body are the basivertebral 
nerves. Ablation of the basivertebral nerve is a safe and effective procedure that is evidence based 
for  appropriately  selected  candidates.  Sayed  and  colleagues  report,  The  United  States 
Preventative Task Force (USPSTF) criteria for grading evidence gives basivertebral nerve ablation 
Level A grade evidence with high certainty that the net benefit is substantial in appropriately 
selected  individuals.  In  a  prospective,  randomized,  multicenter  study,    Khalil  report  that 
basivertebral nerve ablation led to significant improvement of pain and function at three-months 
in  patients  with  chronic  vertebrogenic  related  low  back  pain.  Fischgrund  and  colleagues 
demonstrated that patients treated with basivertebral nerve ablation patients sustained clinical 
improvements in pain and improvement in function at a mean of 6.4 years following treatment. In 
this case, the requested service is likely to be more beneficial than standard therapies such as 
conservative care with physical therapy, medications, and procedural interventions such as lumbar 
medial branch radiofrequency ablation. Therefore, 64628  thermal destruction of intraosseous 
basivertebral nerve is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested authorization and coverage for bilateral reduction mammoplasty. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees symptomatic bilateral macromastia. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. According to American Society of Plastic Surgeons (ASPS) Symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions. ASPS further state that based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. In this case, the patient has severe symptomatic macromastia that has failed reasonable conservative measures. Her physical examination was consistent with significant macromastia that was supported by photographs showing significant shoulder grooving as well. The patient has documented back and shoulder pain, as well as shoulder grooving from bra straps. In addition, she has documented recurrent rashes that have failed conservative measures. Given the documentation submitted for review, the patient has a functional deficit directly related to macromastia that has failed conservative management and would likely improve with surgical correction. Therefore, bilateral reduction mammoplasty is medically necessary in this clinical setting. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 48-year-old male enrollee has requested reimbursement for laboratory testing on 12/2/22. The Health 
Insurer has denied this request and reported that services at issue were investigational for the 
evaluation of the enrollees premature coronary artery disease and hyperlipidemia. The physician 
reviewer found that the current guidelines for the management of cardiac risk and dyslipidemia do not 
recommend the routine performance of specialized tests, including screening lipoprotein(a) levels, in 
the context of assessing coronary risk. Treatment changes or additions based on the results of 
lipoprotein testing has not been shown to improve cardiac outcomes over those achievable through 
treatment based on standard risk factor profiling and a basic lipid analysis. In this patients case, a high 
dose-statin medication is recommended regardless of lipid levels or of lipoprotein(a) levels based on the 
patients known coronary disease. There is a lack of evidence from clinical trials testing the hypothesis 
that lipoprotein(a) reduction reduces the incidence of future cardiovascular events over those 
achievable with standard therapy. Therefore, laboratory testing on 12/2/22 was not likely to have been 
more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 20-year-old male enrollee has requested authorization and coverage for residential substance use disorder treatment from 2/9/16 through 3/10/16. 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 there is a lack of support for the services at issue in this clinical setting. The patient presented with a CIWA score of 1 which is consistent with having mild withdrawals. By 2/9/16, he was not a danger to himself or others. He was medically and psychiatrically stable. He did not require a detoxification protocol. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant a residential treatment services level of care.  The psychiatric evaluation indicated that his impulse control appeared to be good.  He was motivated and appeared to be working the program. Given his recent residential experience in August 2015, he had an educational exposure to relapse prevention, coping skills, and the 12 step program. His family was supportive in his efforts.  He did not require the 24 hour structure of residential and could have safely been treated at an ambulatory level of care such as an intensive outpatient program. As such, the residential substance use disorder treatment from 2/9/16 through 3/10/16 were not medically necessary. Therefore, for the reasons stated above, 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 52-year-old female enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 7/7/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees colonic Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 7/7/14 was not likely to be more effective for this patient than other available treatment options. Menting and colleagues noted that patients with no [antidrug antibody] ADA formation in the first 24 weeks of treatment have little chance of it in the following 24 weeks. The presence of ADA is strongly correlated with adalimumab concentration. In this case, there is documentation of benefit from her use of adalimumab. In such a scenario, the clinical utility is unclear for testing of adalimumab levels. As such, it cannot be concluded that the Prometheus Anser IFX testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy such as adjusting therapy based on available clinical data and observation. Based upon the information set forth above, the testing 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 19-year-old male enrollee has requested reimbursement for behavioral health services from 3/01/17 through 3/10/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Psychiatric Association treatment guidelines for substance use disorders note that  intensive outpatient program level of care can be used as step-down programs for individuals leaving hospital or residential settings who are at a high risk of relapsingto stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. In this patients case, the six dimensions for American Society of Addiction Medicine Level 2.1 (intensive outpatient program) are met. The patient had an unclear risk of withdrawal. There were no medical conditions/complications reported. His emotional/behavioral/cognitive conditions/complications included comorbid anxiety and attention deficit/hyperactivity disorder. Per the records, he was only in the contemplation phase, thus requiring a structured program. The patient had a high likelihood of relapse, given his admission to his parents that he desired to continue substance use as well as his failed urine drug test in March 2018. The patient was unable to engage with his parents in a way that would allow his environment to be supportive. Intensive outpatient program level of care was in accordance with generally accepted standards of medical practice. Therefore, behavioral health intensive outpatient services from 3/01/17 through 3/10/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 61-year-old female diagnosed with ovarian cancer in 2008. She tested negative for BRCA mutations. She has been treated with surgery, Cisplatin, Taxol, Carboplatin, Avastin, Doxil, Gemzar, Topotecan and with olaparib and mTorC 1 and mTorC 2 inhibitor and participation in a clinical trial. A tissue sample from a chest wall metastasis was submitted for FoundationOne testing on 3/21/17. The results showed genomic alterations of PIK3CA, and TP53. Neither of these suggests response to an approved treatment but the PIK3CA suggested possible response to everolimus or temsirolimus. The patient has requested reimbursement for blood testing performed on 3/16/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. FoundationOne tumor testing analyzes a tumor sample for genetic mutations that can help guide treatment options. The standard of care options for ovarian cancer include BRCA1 and BRCA2 testing. The National Comprehensive Cancer Network (NCCN) guidelines state that tumor molecular testing should be done. The recommended testing includes at least BRCA1 and BRCA2, homologous recombination pathway genes, and microsatellite instability (MSI) or DNA mismatch repair (MMR). Testing for BRCA 1 and BRCA 2 has been completed in 2015. Thus, testing for MSI or MMR and testing for homologous recombination pathway genes and for MSI or MMR was medically reasonable and more beneficial than other available standard testing. Given this support, the blood testing performed on 3/16/17 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 60-year-old male enrollee has requested authorization and coverage for nerve stimulator implant. 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 supports the requested services in this case. This patient has an apnea-hypopnea index of 47. He is unable to tolerate continuous positive airway pressure (CPAP) therapy. Clinical studies of the use of hypoglossal nerve stimulation suggest that patients with a body mass index less than 35 benefit from this device. Huntley and colleagues noted that the device may be used successfully in patients with body mass index greater than 32. Upper airway stimulation is a safe and effective therapy for patients with obstructive sleep apnea and represents a powerful option for its surgical treatment. Thus, the requested nerve stimulator implant is likely to be superior over other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for intravitreal Eylea injections provided on 7/26/18. 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 Choroidal neovascularization (CNV) is a common cause of vision loss in patients with pathologic myopia. It is thought to arise from thinning of the retina and choroid from axial elongation, leading to ischemia and expression of vascular endothelial growth factor (VEGF). Since the arrival of anti-VEGF agents, the standard of care for treatment of CNV has shifted from laser to these medications. The most commonly used anti-VEGF agents in the eye are bevacizumab, ranibizumab, and aflibercept. Both aflibercept and ranibizumab have been studied and shown to be effective in the treatment of myopic CNVM. The current medical evidence supports the services at issue in this clinical setting. Therefore, Eylea injections provided on 7/26/18 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis therapy from 7/18/18 forward (H0031, one hour per month, H0032, four hours per month, H2012, four hours per week school, H2012, two hours per week home, H2012, two hours per week parent training, H2019, four hours per week school board certified assistant behavior analyst (BCaBA), H2019, four hours per week home/community BCaBA, H2019, 12 hours per week school, and H2019, 20 hours per week home/community). 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 autism. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. The ABA provider has indicated that the patients problem behavior (i.e., aggression, tantrums) is reportedly occurring at home, in the community, and at school. However, there is a lack of data on the severity of problem behavior at school, just anecdotal reports. Before approval of the codes H2019 and H2012 in school, it is important to first evaluate the need for these services. The BACB Autism Practice Guidelines indicate that treatment should be dictated by assessment which, in turn, informs treatment intensity. Per the medical evidence, ABA is the most evidence based treatment for children on the autism spectrum. Based on the records, H0031, one hour per month, H0032, four hours per month, H2012, two hours per week home, H2012, two hours per week parent training, H2019, four hours per week home/community BCaBA and H2019, 20 hours per week home/community are medically necessary for the treatment of this patient. However, the submitted documentation fails to demonstrate the medical necessity of H2012, four hours per week school, H2019, four hours per week school BCaBA, and H2019, 12 hours per week school. Therefore, a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.