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

Summary Reviewer 2

The patient is a 21-year-old male with a history of gastroesophageal reflux disease (GERD). The patient has been treated with pantoprazole 40 mg. Multiple esophagogastroduodenoscopies performed in 2017 showed antral erythema and Z-line irregularity without esophagitis or Barretts. A video esophagram dated 8/22/17, proved unremarkable. A Bravo pH testing dated 8/18/17 was normal. The patient has requested authorization and coverage for the esophageal sphincter augmentation device (CPT code 43284). The Health Insurer has denied this request as investigational. Based on the clinical documentation submitted for review, the esophageal sphincter augmentation device (CPT code 43284) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, testing showed a normal DeMeester score and zero symptom correlation with acid exposure, whereas esophagitis was absent visually and histologically on three serial esophagogastroduodenoscopies. LINX is indicated in GERD patients refractory to medical management. The patient does not have pathologic GERD, based on objective evidence provided. As such, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be uphel
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 51-year-old female enrollee has requested reimbursement for air ambulance services provided on 11/29/16. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition status post subarachnoid hemorrhage. The physician reviewer found the air ambulance services provided on 11/29/16 were medically necessary for treatment of the patients medical condition. There is sufficient support in the peer-reviewed literature to support the services at issue in this clinical setting. Pollock and colleagues reviewed whether physical rehabilitation approaches are effective in recovery of function and mobility in patients with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach. The authors found that physical therapy improved recovery from stroke. In this case, the patient sustained a stroke and a facility in Washington did not accept her. She was transferred by air ambulance to Colorado for acute rehabilitation. The medical literature supports the therapies delivered at the Craig Hospital in Colorado which is the standard treatment approach for patients status post stroke. Given the patients medical condition, the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 40-year-old female enrollee has requested reimbursement for cytogenomic constitutional microarray analysis performed on 6/14/17. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees recurrent miscarriages. The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG), approximately 50% of all causes of early pregnancy loss are due to fetal chromosomal abnormalities. For this reason, genetic testing is recommended, especially in women of advanced maternal age or following two or more miscarriages. Chromosomal microarray analysis is a method of measuring gains and losses of DNA throughout the human genome. This testing can identify chromosomal aneuploidy and other large changes in the structure of chromosomes that would otherwise be identified by standard karyotype analysis, as well as submicroscopic abnormalities that are too small to be detected by traditional modalities. Accordingly, the cytogenomic constitutional microarray analysis performed on 6/14/17 was medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the testing at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 64-year-old male enrollee has requested reimbursement for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid) 500 mg from 11/2/15 through 11/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees anti-GM1 polyneuropathy and Sjogrens syndrome. The physician reviewer found the medical literature support the superior efficacy of the services at issue in this clinical setting. Polyneuropathy can be idiopathic or can be traced to specific etiologies. Dysimmune neuropathies, with antibodies to gangliosides GM1 and GD1a can present in an acute or a chronic fashion. Patwa and colleagues stated the following, IVIG is effective and should be offered in the long-term treatment of chronic inflammatory demyelinating polyneuropathy (Level A). This patient has had sensory-motor polyneuropathy confirmed, and with associated autoimmune markers. He has tried and failed prednisone and medications for symptom management. IVIG has been administered with benefit, and he has had relapse when not treated. This patient was responsive to treatment with IVIG. As such, injection, immune globulin, (Gammagard liquid), non-lyophilized, (e.g., liquid), 500 mg from 11/2/15 through 11/6/15 was shown to be more effective than standard therapy for treatment of 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays. It is considered a standard of care in guiding treatment decision making. This patient with low risk disease meets criteria for testing. In sum, CPT code 81479 provided on 12/21/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/14/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Therefore, the medical literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. As such, digital breast tomosynthesis performed on 7/14/16 was likely to have been superior to other methods of evaluating this patient. 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on
1/27/20. The Health Insurer has denied this request and reported that the services at issue were
investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the Guardant360 test is a liquid biopsy that analyzes patient plasma for mutations in a panel of 70
genes. Von Hoff and colleagues performed a clinical study directly that compared the use of
targeted agents with conventional chemotherapy approaches. The study involved 86 patients, and
the progression-free survival (PFS) on regimen selected by molecular profiling was compared to
the PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a
27% survival advantage. This trial has very significant results for patients with stage IV tumors.
In most instances of visceral disease or lymph node involvement, testing can be performed on the
excised tissue. However, in certain cases, such as bone metastases, the decalcification process
makes the material unsuitable for gene sequencing. Thus, liquid biopsy is specifically mentioned
in the National Comprehensive Cancer Network (NCCN) guidelines as an alternative approach
when the tissues are less accessible. The oncologistas progress notes indicate that the patient has
metastatic disease involving the cervical and thoracic spine. The anatomical locations are difficult
to directly sample without a significant invasive procedure with its own morbidities. Thus, the
patientas clinical situation fits the scenario outlined in the NCCN guidelines for performing the
Guardant360 test. Therefore, genetic testing performed on 1/27/20 was likely to have been more
beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 39-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 9/6/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees breast examination. 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. In this particular patient, while the presence of a nipple discharge is concerning, statistically it is more commonly either physiologic or secondary to a benign etiology. As noted by Patel and colleagues, the cause of nipple discharge is usually benign, so the primary goal of evaluation and management is separation of patients with pathologic causes of discharge from those with benign or physiologic causes. For this reason, tomosynthesis is warranted. This is especially true considering the heterogeneously dense nature of her breasts. It is specifically this type of patient with dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis provided on 9/6/16 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 diagnostic procedure 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 17-year-old male who has been diagnosed with autism spectrum disorder and an intellectual disability. The parent has requested reimbursement for ABA performed from 7/01/20 through 12/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Papatola and Lustigas definition of medical necessity entails ahealth-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care.a This patientas request fails to meet criterion (a), as many of the goals are not linked to their autism diagnosis. Specifically, the goals of preparing food and washing dishes are tied to executive functioning, but it is unclear how exactly executive functioning is being measured and whether these specific tasks are improving executive functioning and/or ameliorating the symptoms of autism. Further, the insured fails to meet criterion (c), as many elements or missing from the treatment plan, which will be described in greater detail below. Both the Council of Autism Service Providers (CASP) and the ABA Coding Coalition outline the necessary elements of treatment plans. While the patientas treatment plan includes many of these items, several are missing, which makes it difficult to ascertain progress and necessity of the request. Specifically, the treatment authorization request fails to include dates of proposed mastery. Data on almost all goals (with the exception of minimal challenging behavior data), transition and discharge planning is lacking specific measurable criteria. The medical necessity of the goals are unclear, and there has been an overall lack of progress on most goals (at least how it can be interpreted from the lack of data provided) with no explanation of why. Given these missing elements, the lack of progress, and the emphasis on non-autism related goals, the request fails to meet medical necessity. Therefore, ABA performed from 7/01/20 through 12/31/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 14-year-old male enrollee has requested reimbursement for psychological testing performed on 3/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had a previous diagnosis of attention deficit/hyperactivity disorder and had previous psychological testing prior to the disputed date of the requested testing.  Per the records, he was benefiting from his current outpatient psychotherapy, and his behaviors have improved in school over the past year. The records do not indicate why the testing would need to be repeated in this patients case. The documentation does not indicate that the patient had a low general cognitive ability or other neurological deficits that would require further and more complex evaluation. The current standard of care for diagnosis of attention deficit/hyperactivity disorder is a full clinical evaluation. Attention deficit/hyperactivity disorder is a clinical diagnosis. The medical evidence does not support the services at issue in this clinical setting. Thus, psychological testing performed on 3/15/18 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 64-year-old male enrollee has requested reimbursement for a LifeVest provided from 6/2/14 through 9/2/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that based on the records provided for review, the patient is a 64-year-old male with a newly recognized non-ischemic cardiomyopathy and congestive heart failure. In this circumstance there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (more than 90 days) where continued left ventricular dysfunction (ejection fraction is less than or equal to 35%) is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Medical studies assessing efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction less than or equal to 35% before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al; Steinbeck, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation.  For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 48-year-old male enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees squamous cell carcinoma. The physician reviewer found that there is a lack of clinical data in the medical literature to suggest that treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). In this patients case, the comparative planning showed no clinically significant benefit with treatment with proton beam therapy over standard photon techniques, as all standard dose metrics are met with the photon plan. In sum, proton beam therapy is not likely to be more effective than other treatment alternatives in this patients case. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 20-month-old female enrollee has requested authorization and coverage for Synagis.  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 the submitted documentation supports the requested services in this clinical setting.  Fauroux and colleagues noted increased respiratory morbidity in infant born less than 33 weeks gestation even in the absence of bronchopulmonary dysplasia.  This patient was born prematurely at 33 weeks twin gestation with a medical history significant for chronic lung disease, tracheoesophageal fistula complicated by esophageal tear and difficulty managing secretions.  The records document severe gastroesophageal reflux disease and feeding intolerance requiring gastrostomy tube feedings.  Because of her prematurity complicated by chronic lung disease, gastroesophageal reflux disease, and tracheoesophageal fistula, she is at risk for severe respiratory syncytial virus disease.  Therefore, Synagis 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 3/29/18. 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 the services at issue were not likely to have altered treatment and surveillance recommendations. The medical evidence does not support the services at issue in this clinical setting. Thus, DecisionDx-Melanoma testing performed on 3/29/18 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.