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

Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement for residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15. 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 not medically indicated for this patient during the dates in dispute. According to the documentation submitted for review, the patient presented to residential treatment on 3/6/15 with mild. He was not a danger to himself or others. There were no emotional, behavioral, or cognitive barriers requiring residential treatment. He was psychiatrically stable. Although his liver function tests were elevated, he was medically stable. He participated in the program and was motivated. He did not require 24-hour monitoring at residential level of care. As of 3/25/15, partial hospitalization program services were not clinically indicated. The patient no longer had PAWS and he was not at risk to himself or others. He was counseled regarding the need to monitor his liver function tests and liver health. His overall mood was euthymic. As of 3/25/15 he could have been stepped down to a lower level of care. Further, the intensive outpatient program services were not indicated for this patient. As of 4/17/15, he had a sponsor, and he was actively attending meetings/groups, and was employed. He was highly motivated. His mother was participating in family sessions. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. Therefore, the residential treatment, partial hospitalization program services and intensive outpatient program services provided from 3/6/15 through 5/3/15 were not medically necessary. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 29-year-old male enrollee has requested authorization and coverage for implant of neuroelectrodes (InterStim, under fluoroscopy guidance). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees neurogenic bladder.   The physician reviewer found this patients provider has recommended placement of InterStim for treatment of non-obstructive urinary retention. However, the diagnosis of non-obstructive urinary retention is not supported by the documentation provided for review in this case. The patient has a sensation of incomplete emptying. However, he has never catheterized for urinary retention and the post-void residual was normal at 64 cc on 7/23/15. The urodynamic study reportedly had an elevated post void residual but the study is not available for review. The study also shows detrusor hyperreflexia which can explain nocturia and frequent small voids. This patients symptoms would be best treated by an anticholinergic medication. In addition, it is unclear if the elevated post void residual reported on the urodynamic study is from poor detrusor contraction, detrusor sphincter dyssynergia, or bladder outlet obstruction. This information would only be available from a pressure flow study which is not available for review. Thus, the diagnosis of non-obstructive urinary retention cannot be justified and the requested implant of neuroelectrodes (InterStim, under fluoroscopy guidance) is not supported as medically necessary. Based on the foregoing discussion, the requested service is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


The parent of a four-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA) genetic testing performed on 9/16/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation the enrollees developmental delays. The physician reviewer found that chromosomal microarray genetic testing has become standard of care to evaluate children with developmental disabilities. Henderson and colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that their results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Similarly, Riggs and colleagues reported that 7% of microarray results impact clinical management, a rate which is similar to other genetic tests. Given the support in the peer-reviewed literature, the chromosomal microarray genetic testing performed on 9/16/15 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: Overturned

Summary Reviewer 3


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 7/29/16 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 23-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance abuse partial hospitalization program (PHP) services provided from 5/28/15 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 enrollees opiate dependence and depression.The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines recommend that PHP treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance uselack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. As documented in this patients case notes, he has poor coping skills, is impulsive, has low self-esteem, and demonstrates a pattern of being unable to abstain from drugs and alcohol as evidenced by multiple treatment episodes. Consistent with the American Society of Addiction Medicine (ASAM) criteria, he requires safe and stable living environments in order to develop recovery skills, and the services at the PHP level of care are thus appropriate. All told, the PHP services provided from 5/28/15 forward were and are medically necessary for treatment of this patients medical condition.Therefore, the Health Insurer's denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 43-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/2/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved since the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. As the 2D images were most likely reconstructed from the primary tomosynthesis acquisition, a routine mammogram would have been sufficient. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to a prior mammogram from eight years earlier, and especially when there is considerable fatty change. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/2/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. 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 had significant right osteoarthritis following wrist fracture 20 years ago. A review of the medical literature shows that the requested procedure does have a moderate amount of good quality literature to support efficacy in patients who are otherwise only candidates for wrist fusion surgery. The submitted records do demonstrate that the patient has failed an appropriate course of conservative management. There is sufficient support for the services at issue in this clinical setting. Therefore, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 33-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/30/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the submitted medical records fail to demonstrate the superior effectiveness of the services at issue.  Some evidence exists that low serum levels of infliximab or adalimumab and/or the presence of antibodies to infliximab or adalimumab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, Anser IFX testing performed on 4/30/15 was not likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 28-year-old female enrollee has requested reimbursement for CPT code 92025 (computerized corneal topography, unilateral or bilateral, with interpretation and report) provided on 6/02/15.  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 current medical evidence does not support the services at issue in this patients case.  Corneal topography provides a map of the cornea.  It is most often used to determine if there is any sign of ectasia.  While there can be corneal abnormalities in patients with dry eyes, the use of topography purely for the management of the dry eyes is not considered standard of care.  Likewise, since the patient could see 20/20 and the refraction showed low astigmatism, the suspicion for corneal ectasia is very low. Therefore, based on the medical records provided, the services at issue were not likely to have been of greater benefit than other treatment options.  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: Experimental
Decision: Upheld

Summary Reviewer 3


A 32-year-old female enrollee has requested reimbursement for the laboratory testing provided on 6/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees miscarriage. The physician reviewer found that the laboratory studies that were ordered for this patient have not been recommended by American College of Obstetricians and Gynecologists (ACOG) as beneficial for patients who have had first trimester pregnancy loss. Further, the use of anticoagulation, aspirin, or both has not been shown to reduce the risk of early pregnancy loss in women with thrombophilias. Since there is no effective treatment associated with identification of abnormalities in these laboratory studies, there is no benefit to the patient in obtaining the studies. Thus, the laboratory testing provided on 6/6/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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 62-year-old female enrollee has requested reimbursement for ChemoFX assay performed on 5/08/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found ChemoFx is an attempt to determine the likelihood of a specific chemotherapeutic agent being effective in a patient, by testing the growth of an individuals cancer in an environment of various agents in vitro.  The hope is that drugs to which the cancer cells will respond to in vitro will then be clinically useful in that patient.  Such personalized selection would then spare the patient the toxicity of drugs that would not be useful.  There have been many such assays developed over the years.  As yet, none has convincingly demonstrated that selecting the specific chemotherapeutic regimen under the guidance of this assay has given the patient a significantly better survival, when compared to selecting a regimen based on known clinical studies and standards.  At this time, the evidence is insufficient to use the information from these assays to supplement standard of care chemotherapy decisions.  All told, ChemoFx assay performed on 5/08/15 was not likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for the lab testing provided on 11/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees migraines, mild memory impairment, and prior syncope. The physician reviewer found that there is a lack of conclusive evidence of a linkage between migraines and homocysteine levels (Lippi, et al). Further, the current guidelines from the American Heart Association and American Stroke Association do not support the performance of this testing (Goldstein, et al). In addition, the current practice guidelines from the American College of Medical Genetics (ACMG) do not support the performance of testing for MTHFR (Hickey, et al). With regard to Factor V Leiden, Grody and colleagues report that the ACMG does not recommend random screening of the general population for factor V Leiden. Routine testing is also not recommended for patients with a personal or family history of arterial thrombotic disorders (e.g., acute coronary syndromes or stroke) except for the special situation of myocardial infarction in young female smokers. In this case, there was no reported family history noted of a hypercoagulable condition. Nor does the patient have a history of a thrombus or other similar condition. Given that the patient did not present with a condition related to a coagulable disorder the need for testing for Factor V Leiden is not supported in the records provided for review. All told, the lab testing provided on 11/28/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of an 11-year-old male enrollee has requested authorization and coverage for Epidiolex Solution (cannabidiol). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees intractable epilepsy. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has medically refractory epilepsy, having been tried on multiple anticonvulsant medications without obtaining seizure control. He has structural brain abnormalities that increase his risk of having intractable epilepsy. Silvestro and colleagues noted, Cannabidiol (CBD) is one of the cannabinoids with non-psychotropic action, extracted from Cannabis sativa. CBD is a terpenophenol and it has received a great scientific interest thanks to its medical applications. This compound showed efficacy as anti-seizure, antipsychotic, neuroprotective, antidepressant and anxiolytic. The neuroprotective activity appears linked to its excellent anti-inflammatory and antioxidant properties. The authors stated, The results of scientific studies obtained so far for the use of CBD in clinical applications could represent hope for patients who are resistant to all conventional anti-epileptic drugs. Epidiolex has been demonstrated to be an effective long-term treatment option in Lennox-Gastaut syndrome and Dravet syndrome, two forms of intractable generalized epilepsy syndromes in children, and is approved by the U.S. Food and Drug Administration (FDA) for those conditions. The drug does not have biological specificity for these two conditions, however. OConnell and colleagues noted that open-label studies with 100mg/ml CBD (Epidiolex, GW Pharmaceuticals) have provided additional evidence of its efficacy along with an adequate safety profile (including certain drug interactions) in children and young adults with a spectrum of treatment resistant epilepsies. There is sufficient support for the requested medication in this clinical setting. Therefore, Epidiolex solution (cannabidiol) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 56-year-old female enrollee has requested reimbursement for gene test (Breast Cancer Index) performed on 1/6/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who had a history of breast cancer. The physician reviewer found that the Breast Cancer Index test was investigational for the evaluation of this patient. Randomized prospective clinical trials showing progression free survival or overall survival benefit using this test are lacking. As such, recommending this test remains provocative and debatable. The results from the test showed very low risk for recurrence. The adjuvant hormonal therapy was based on stage at diagnosis and hormonal status. Accordingly, the gene test (Breast Cancer Index) performed on 1/6/17 was not likely to have been superior over the other methods of evaluating this patients medical condition.  
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.