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

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided from 11/27/17 through 1/20/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. With regards to risk of harm, the records support a score of 3 due to her inability to control impulsive aggression towards staff. In terms of her functional status, the records support a score of 4 due to deterioration in interpersonal interactions and serious school disruption. With regards to her comorbidity, the records support a score of 1. The patient did not have active medical problems and did not have a recent history of substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had school disruption and lack of peer support. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 5 due to minimal positive treatment response in the past at numerous levels of care. In terms of acceptance and engagement of the patient, the records support a score of 5. The patient had minimal insight into her treatment needs. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians. Thus, the patient has a composite score of 24, which is consistent with residential level of care. The medical evidence supports the services at issue in this clinical setting. Therefore, residential mental health treatment for children and adolescents provided from 11/27/17 through 1/20/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for the mobile heart monitor provided on 8/2/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees palpitations. The physician reviewer found that he use of different types of ambulatory electrocardiogram monitoring for arrhythmias has evolved over the past 10-15 years (Crawford, et al). Newer patch based systems for two weeks and mobile outpatient telemetry for longer times have developed and are recommended for infrequent symptoms as in this clinical setting. The Heart Rhythm Society noted that the choice of monitor needs to be matched to the individual patients symptom frequency (Steinberg, et al). If symptoms are not present daily, then longer duration monitors are recommended. Given these findings, the mobile heart monitor provided on 8/2/17 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 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: Upheld

Summary Reviewer 

The patient is a 30-year-old male with a history of gynecomastia. Therefore, the patient has requested authorization and coverage for suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the case was previously reviewed, and additional documentation was submitted for reconsideration. Additional medical information received for review included an email from the provider indicating that a surgical facility charges for liposuction for time and supplies, and there would still be a charge even if he charged no professional fee.  On 5/09/20, the provider noted, aThe bilateral breasts demonstrate Simon Grade IIa gynecomastia. There are tender subareolar masses bilaterally measuring approximately 2 cm x 3 cm x 3 cm.a He also reported that the patient adesires surgical excision of gynecomastia in addition to potential suction lipectomy.a The American Society of Plastic Surgeons reports the following gynecomastia scale adapted from the McKinney and Simon, Hoffman and Kohn scales: grade I a small breast enlargement with localized button of tissue that is concentrated around the areola; grade II - moderate breast enlargement exceeding areola boundaries with edges that are indistinct from the chest; grade III -moderate breast enlargement exceeding areola boundaries with edges that are distinct from the chest with skin redundancy present; grade IV - marked breast enlargement with skin redundancy and feminization of the breast. In this case, photographs demonstrate chest enlargement that significantly exceeds the 2 cm x 3 cm x 3 cm size of the glandular tissue, so that the chest enlargement constitutes mixed gynecomastia, with a mixture of both true glandular gynecomastia and fatty tissue constituting pseudogynecomastia. There is no change in determination that liposuction is an optional surgical technique that can be used during gynecomastia surgery and is not a separate surgical procedure for the patient for treatment of gynecomastia. Liposuction of the chest area well beyond the limited area of the gynecomastia excision can be performed for improved cosmetic appearance, particularly when the gynecomastia is mixed and there is some degree of pseudogynecomastia present. Liposuction for that purpose would be cosmetic and not medically necessary. Thus, suction assisted lipectomy trunk (CPT 15877) is not medically necessary as a separately billed procedure. CPT 19303 is not medically necessary because it applies to a mastectomy in a woman. In sum, suction assisted lipectomy, trunk (CPT 15877) and mastectomy, simple complete (CPT 19303) are not medically necessary for the treatment of this patient. The Health Insurer has approved the appropriate CPT code in this case (CPT code 19300).
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 33-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees small bowel Crohns disease. The physician reviewer found antidrugs 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. There is a lack of 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 (Steenholdt, et al; Nanda, et al). In addition, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Moreover, it has not 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 this case, the patient showed good clinical response to Remicade, and no change were made to her Remicade dosing regardless of Anser findings. Thus, the Anser IFX testing performed on 2/18/16 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: Overturned

Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 8/9/16. 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 there is a lack of peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 8/9/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested reimbursement for conjunctivorhinostomy without tube (CPT 68745) for performed on 10/21/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees blocked tear duct with a possible stone. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the services at issue. Conjunctival dacryocystorhinostomy is generally the standard approach in treating epiphora caused by lower lacrimal tract obstruction. However, conventional dacryocystorhinostomy works well for the lower drainage system, but not as well for the upper system. In this case, the patient underwent conjunctivorhinostomy for the treatment of upper lacrimal drainage system. Therefore, the conjunctivorhinostomy without tube (CPT 68745) for performed on 10/21/14 was medically necessary in this patients case. For the reasons provided, 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 1 
 
A 24-year-old male enrollee has requested reimbursement for an implantable interstitial glucose 
sensor on 1/7/22. The Health Insurer has denied this request and reported that the device at 
issue was investigational for the treatment of the enrollees type 1 diabetes. The physician 
reviewer found that the Eversense is an implantable real time continuous glucose monitoring 
(CGM) device which recently became available.  The Eversense CGM has an accuracy comparable 
to other real-time CGM devices.  Unlike other available CGM systems, the Eversense system 
requires a finger stick glucose measurement approximately every 12 hours for recalibration in 
order to accurately measure the concentration of interstitial tissue fluid glucose. Furthermore, a 
trained health care worker needs to surgically remove the Eversense sensor after 90 days in the 
United States. While the patients glycemic control has improved with the Eversense CGMS, there 
is lack of evidence in current medical literature that an implantable sensor is more beneficial than 
standard CGM systems. Therefore, an implantable interstitial glucose sensor on 1/7/22 was not 
likely to have been more beneficial for treatment of the patients condition than any available 
standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 9/04/18. 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 the medical evidence supports the services at issue in this clinical setting. Corneal collagen crosslinking has been U.S. Food and Drug Administration (FDA) approved as a treatment for progressive keratoconus. In this case, based on the patients young age and significant progression in the right eye, he was at risk for further progression of the keratoconus. Thus, corneal collagen crosslinking performed on 9/04/18 was likely to have been superior over other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 59-year-old male with diabetes, hypertension, and documented obstructive coronary disease, including myocardial infarction, coronary stent placement and coronary artery bypass surgery. The records noted hyperlipidemia, and the patient is intolerant of statin medications and ezetimibe. The patients low-density lipoprotein (LDL) cholesterol is reported at 151 mg/dl. The patient has requested authorization and coverage Repatha SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The Health Insurer noted that the preferred formulary alternative, Praluent, has not been tried or failed. Based on the records provided, the patient has documented obstructive coronary disease and hyperlipidemia with intolerance to multiple statins and ezetimibe but no documented trial of Praluent.  Praluent (alirocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, Praluent has shown to be safe and effective at significantly reducing cholesterol and has been associated with improved cardiac outcomes. There are a lack of trials that adequately compare or conclusively demonstrate an advantage with Repatha SureClick over Praluent. Based on the documentation provided, the preferred formulary alternative Praluent should be effective and sufficient in this circumstance. Thus, Repatha SureClick is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 44-year-old female enrollee has requested reimbursement for an AmniSure test that was performed on 4/7/14. The Health Insurer has denied this request indicating that the test at issue is considered investigational for evaluation of the rupture of the fetal membrane. The physician reviewer found that AmniSure is recognized with generally accepted professional medical standards as being safe and effective. This test is well supported and recommended in difficult diagnostic cases.  In this case, the early gestational age of this patient makes accurate diagnosis especially important because this could pose difficult clinical decisions. Accurately diagnosing premature preterm rupture of membranes (PPROM) is crucial to the well-being of the mother and fetus. AmniSure is approved by the Food and Drug Administration (FDA) and is generally recognized as a safe and effective test for the diagnosis of PPROM.  In this patients case, the AmniSure test performed on 4/7/14 was likely to be superior for evaluation of this patient than any available standard test for PPROM. Based upon the information set forth above, the test 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 68-year-old male enrollee has requested authorization and coverage for eye medication/eye drops (latanoprost 0.005%, one drop twice daily). The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees primary open angle glaucoma. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication dosage. Latanoprost 0.005% is prescribed as once daily dosing. There is a lack of evidence demonstrating that twice daily dosing is more effective than once daily dosing. The medical evidence does not support the requested medication dosage in this clinical setting. Thus, eye medication/eye drops (latanoprost 0.005%, one drop twice daily) is not medically necessary for the treatment of this patient. Therefore, the requested medication dosage is 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 44-year-old male enrollee has requested reimbursement for the substance abuse partial hospitalization program (PHP) services provided from 11/10/15 through 12/3/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse.   The physician reviewer found the records provided for review indicate that this patient did not experience any withdrawals and did not endorse cravings during the period under dispute. He was not a danger to himself or others. He was medically stable. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant treatment at the PHP level of care. His mood was stable and he showed no psychiatric symptoms that required monitoring multiple days per week for multiple hours per day. He was engaged in groups and individual treatment, but did not go to outside meetings and did not have outside support systems in place. He had a history of multiple treatments since 2014, and almost continuous treatment since September 2015. During this course of treatment, the patient did not appear to have progressed significantly enough to warrant PHP level of care. The trauma and resolution work needed could have been safely and adequately managed in the outpatient setting. Further relapse prevention could have taken place on an outpatient basis via 12-step meetings, obtaining of a sponsor, and counseling. He did not require PHP for his psychiatric medication management, as this too could have been accomplished on an outpatient basis. All told, the PHP services provided from 11/10/15 through 12/3/15 were not medically necessary for treatment of this patients behavioral health issues.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

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 in his case, the records document treatment-resistant, recurrent major depressive disorder. Per the submitted documentation, TMS was an effective treatment for patient in 2019, despite needing maintenance treatments at that time. During this episode of depression, the patient again presents with similar Patient Health Questionnaire 9 (PHQ-9) scores as in early 2019 pre-treatment. The medical evidence supports TMS in this clinical setting. 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that there are many agents with activity against recurrent ovarian cancer. Thus, treatment off-label is very common. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues published a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. The patient is out of standard options and will be offered something off-label. The mutational testing as ordered was medically appropriate. Thus, genomic analysis performed on 6/15/17 was 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 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  
The patient is a 15-year-old male with a history of chronic migraine. The patient has undergone 
evaluation magnetic resonance imaging (MRI) of the head with and without contrast, which was 
interpreted as normal. The patient has reportedly experienced excellent results with abortive 
therapy in the form of intranasal ketorolac tromethamine solution 15.75 mg/spray. The provider 
has recommended continued treatment with ketorolac tromethamine solution spray. The Health 
Insurer has denied the requested medication as not medically necessary. This denial is the subject 
of  this  appeal and  determination.   The  physician reviewer  found  that  the  patients records 
document a history of chronic migraines. As reported by the provider, the patient has been treated 
with  Migrelief,  acupuncture,  Advil,  and  nortriptyline  without  substantial  improvement  in 
symptoms. The patients provider has recommended treatment with ketorolac tromethamine 
solution spray. As noted in the medical literature, ketorolac tromethamine solution spray has been 
demonstrated to be effective in the management of patients with chronic migraine who have not 
responded to, or are in intolerant to treatment with, other currently available mediations for 
migraine. In one study, Rao and colleagues concluded that, This study supports that ketorolac 
nasal spray is superior to placebo and that it is non-inferior to sumatriptan nasal spray for the acute 
abortive treatment of migraine. Considering this patients documented success with intranasal 
abortive therapy with ketorolac tromethamine solution at a dose of 15.75 mg/spray, continued 
treatment with this medication is appropriate. Moreover, treatment with ketorolac tromethamine 
solution is indicated to help avoid emergency department services should the patients headache 
progress to persistent migraine. All told, the requested ketorolac tromethamine solution 15.75 
mg/spray is medically necessary for treatment of this patient.