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

Summary Reviewer 

A 35-year-old female enrollee has requested authorization and coverage for polysomnography. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the patient is at intermediate risk for obstructive sleep apnea, which could contribute to her depression and anxiety. Per the records, she has symptoms of sleep apnea. The patient is not a good candidate for a home sleep study, given her intermediate risk with a high possibility of a false negative study. The patient will need an in-laboratory diagnostic polysomnography (95810) or split night sleep study (95811) to accurately evaluate and treat her sleep disorder breathing. Therefore, the requested polysomnography is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/19/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented for a breast examination.  The physician reviewer found that the 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 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In this clinical setting, a routine mammogram would have been sufficient.  Digital breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality. Therefore, breast tomosynthesis performed on 7/19/16 was not 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 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 2

A 54-year-old male enrollee has requested authorization and coverage for neurostimulator electrode array and pulse generator. 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 patient has obstructive sleep apnea and has no nasal obstruction. Drug-induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse. The patient has not been able to tolerate the continuous positive airway pressure device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. The patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure, anterior posterior collapse, and body mass index and apnea-hypopnea index within FDA criteria. In sum, CPT codes 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is sufficient evidence in the medical literature to support the use of home allergy immunotherapy.  The current medical evidence supports the services at issue in this patients case.  Per the medical records, home administration of allergens immunotherapy was medically appropriate.  Therefore, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 was likely to have been more efficacious than other methods of treating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 66-year-old male enrollee has requested reimbursement for positron emission tomography (PET) scan performed on 9/06/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees tumor of suprahyoid epiglottis. The physician reviewer found that the medical evidence supports the services at issue in this clinical setting. PET/CT has an important role in the diagnosis and treatment of head and neck cancer. The technique can aid in the detection of an unknown primary tumor, assist in locoregional staging, evaluate for distant metastases or second primary tumors, and be a component of restaging and tumor surveillance. PET/CT is also used for precise delineation of the tumor volume for radiation therapy planning, and for treatment response monitoring, by detecting residual or recurrent disease. This patient was diagnosed with squamous cell carcinoma. The PET scan was medically necessary for staging and treatment planning. Thus, PET scan performed on 9/06/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 45-year-old male enrollee has requested authorization and coverage for maxillary and mandibular osteotomies with advancement. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees obstructive sleep apnea (OSA).  The physician reviewer found that Maxillomandibular advancement can be an effective treatment for treatment of sleep disordered breathing based on several case series but more rigorous evaluation of the procedure is lacking (Prinsell). Current practice parameters list this procedure as an option for patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Aurora, et al). Traditionally, mandibular advancement devices have been used for mild to moderate sleep apnea. This patients provider states that a mandibular advancement device is not likely to be effective in treating the patients sleep apnea. However, the most recent guidelines do not exclude the use of maxillomandibular advancement in severe OSA (Ramar, et al). In summary, the patient does have severe OSA and is CPAP intolerant but he has not tried a mandibular advancement device, a treatment which could result in adequate control of his sleep disordered breathing. Since there is another reasonable, non-surgical option available to him, the requested maxillary and mandibular osteotomies with advancement are not medically necessary. Based on the foregoing discussion, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment from 7/01/15 through 7/31/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  The current medical evidence supports residential treatment in this clinical setting.  Per the documentation from his treatment providers, including the psychologist who evaluated him during this time, the patient was likely to have relapsed into his previous behaviors if discharged to a lower level of care.  The records describe the patient as superficial and able to present a false front to his treatment team.  Thus, he was not internalizing the changes needed to avoid a relapse.  All told, residential treatment from 7/01/15 through 7/31/15 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 69-year-old female enrollee has requested reimbursement for lipoprotein (a) testing performed on 2/09/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrolleeas condition than any available standard therapy. The physician reviewer found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein (a) testing. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, lipoprotein (a) testing performed on 2/09/21 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the decision DX melanoma assay has been developed in patients with stage I and II cutaneous melanoma.  However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. It does not aid in the decision for re-excision. In sum, Decision DX melanoma assay performed on 5/19/16 was not likely to be of greater benefit than available standard therapy.  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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/07/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing were unlikely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma testing performed on 2/07/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that percutaneous tibial nerve stimulation may have a role in reducing uninhibited bladder contractions when first-line behavior modification and second-line medical therapy have failed to resolve symptoms of overactive bladder. In this patients case, there is also the complexity of past interventions, ongoing neuropathic issues, and diabetes increasing the risk of urinary tract infections. It is not standard of care to proceed with percutaneous tibial nerve stimulation prior to exhausting standard first-line behavior modification and second-line medical therapy. Percutaneous tibial nerve stimulation has not be shown to be more effective than these treatment approaches per the current evidence. Therefore, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been of greater benefit than other available 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 51-year-old male enrollee has requested authorization and coverage for low back surgery to be done in two stages (stage 1, anterior lumbar fusion with one day stay followed by stage 2, posterior fusion also with one day stay). 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 there is sufficient support for the requested services in this patients case. A review of the literature indicates moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability. Degenerative disc and facet joint disease of the lumbar spine is common in individuals in this age group, and is one of the most frequent causes of pain and associated disability. Lumbar spondylosis may result in mechanical back pain, radicular pain, reduced mobility and poor quality of life. Surgical interbody fusion of degenerative levels is an effective treatment option to stabilize the painful motion segment, and may provide indirect decompression of the neural elements, restore lordosis and correct any associated deformity. The provider has suggested the fusion procedure at L4-5 in two stages due to the large size of the patient, which is reasonable, appropriate, and medically necessary in this case. Therefore, low back surgery to be done in two stages (stage 1, anterior lumbar fusion with one day stay, followed by stage 2, posterior fusion also with one day stay) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 47-year-old female enrollee has requested reimbursement for proton beam therapy provided on 5/20/19 through 7/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that standard treatment for rectal cancer is with photon techniques. Currently, there is a lack of clinical data in the medical literature to suggest that treatment with protons offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the rectum.  Consensus group guidelines do not support the use of proton therapy in this setting. Also, there is a lack of phase 3 studies that demonstrate proton therapy is associated with less side effects compared to standard therapy with photons in patient with pelvic malignancies. The dose comparison was reviewed as well and showed no clinically significant benefit with the use of protons over standard techniques, as all standard dose metrics are being met with the standard plan. Thus, proton beam therapy provided from 5/20/19 through 7/12/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. 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 that the testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser IFX Test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. 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. Some evidence exists that low serum levels of infliximab or adalimumab or the presence of IFX or ADA 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, there is a lack of sufficient evidence in the peer-reviewed literature to establish the testing at issue as 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 a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 35 hours per week of direct applied behavioral analysis (ABA) therapy and 3.5 hours per week of oversight provided from 7/1/16 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 enrollees autism.  The physician reviewer found that in this clinical setting, ABA therapy is medically necessary for treatment of the patients medical condition. The study by Mohammadzaheri and colleagues found that ABA is effective for treating disruptive behaviors in school aged children with autism.  Based on the documentation submitted for review, the patient requires a higher level of ABA therapy due to maladaptive behaviors including aggression, non-compliance, and a high level of self-injury. In addition, the patient has not mastered a majority of the goals included in the most recent progress report. In sum, the medical necessity for 35 hours per week of direct ABA therapy and 3.5 hours per week of oversight provided from 7/1/16 forward has been established as 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: Upheld

Summary Reviewer 2


A 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that exome genetic sequencing has been shown to be beneficial for the purposes of genetic counseling and potential future disease modification. The medical evidence does not indicate therapies available for the treatment of cerebral palsy that are dependent upon the results of genetic sequencing. The general consensus with regard to genetic sequencing is that although very beneficial academically in terms of disease diagnosis, it has proven beneficial in disease management rarely. Therefore, the requested services are not likely to be of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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

The parent of a 14-year-old female enrollee has requested authorization and coverage for colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollee, who has a history of bowel incontinence. The physician reviewer found that colonic manometry is indicated for the planning of surgical interventions in patients with constipation refractory to medical therapy. These interventions may include, but are not limited to, appendicostomy and cecostomy for antegrade enemas. Appendicostomy has been specifically mentioned as a consideration for this patients care. The utility of colonic manometry for this purpose has been described in the clinical literature. In sum, colon motility (manometric) study, minimum six hours continuous recording (including provocation tests, e.g., meal, intracolonic balloon distension, pharmacologic agents, if performed), with interpretation and report, procedure code 91117, and associated one day inpatient admission are likely to be superior over other methods of evaluating this patient. Based upon the information set forth above, the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.