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

Summary Reviewer 


A 52-year-old male enrollee has requested reimbursement for emergency room physician services provided on 6/19/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. The patient presented with an acute injury that was significantly complex that required emergent physician services. There was serious impairment of the lower lip that could affect his oral competence (dysfunction), additional bleeding from the transected labial artery and significant deformity of the lower lip, without emergent treatment. Emergency room personnel did not have the expertise to sufficiently treat this patient and plastic surgery was consulted. Based on the documentation submitted for review, the patient was within an acute phase of injury and thus emergent closure was necessary. Further delaying treatment placed the patient at risk for functional impairment of the mouth, bleeding and significant deformity. Thus, the emergency room physician services provided on 6/19/17 met prudent layperson criteria for emergency care.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that King and colleagues noted, aThe literature on sacral lateral branch interventions is sparse. One study demonstrates the face validity of multisite, multi-depth sacral lateral branch blocks for diagnosis of posterior sacroiliac complex pain. Some evidence of moderate quality exists on therapeutic procedures, but it is insufficient to determine the indications and effectiveness of sacral lateral branch thermal radiofrequency neurotomy, and more research is required.a Aydin and colleagues noted, aThe meta-analysis demonstrated that radiofrequency ablation is an effective treatment for sacroiliac joint pain at 3 months and 6 months. This study is limited by the available literature and lack of randomized controlled trials. Further standardization of RFA lesion techniques needs to be established, coupled with prospective randomized controlled trials.a This patient was being treated for chronic low back pain, lumbar spondylosis with radiculopathy, and sacroiliitis. He presented on 9/28/21 reporting almost complete relief of his low back pain from the sacroiliac joint injection on 6/18/21; however, the pain returned about two weeks after the injection, and gradually became severe again. He has current complaints of persistent pain in the left low back. The pain remains severe at 8/10, requiring him to continue to take medications. Examination reveals mild restriction of flexion and extension. There is tenderness to palpation at the lower lumbar levels spinous processes, and left paraspinal and gluteal musculature. There is moderate tenderness to palpation of the left posterior superior iliac spine. There is a positive left FABER test, thigh thrust and compressive tests. Strength testing reveals weakness of the left dorsiflexor at 4/5. Magnetic resonance imaging (MRI) is noted from 8/26/21 to show no change from prior examination on 4/29/19; interval spinal fusion at L5-S1. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There has been no literature consensus on which nerves are most appropriate to lesion. In addition, multiple other plausible pain generators (including at the lumbosacral spine) are evident. Therefore, the requested radiofrequency ablation is not likely to be more beneficial for treatment of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for CPT code 31299 performed on 12/22/20. 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 the current medical evidence supports the requested services in this clinical setting. The patient has a history of nasal obstruction, septal deviation and turbinate hypertrophy. The patient had used nasal sprays in the past, with minimal improvement. Cryotherapy has been found to benefit patients with chronic nasal drainage. Gerka Stuyt and colleagues performed a prospective single-arm trial of 24 adult patients at seven locations within a large health maintenance organization. The authors noted, aCryoablation of the posterior nasal nerve shows improvement in nasal symptoms over a one-year period and is consistent with other published data.a Ow and colleagues noted, aCryotherapy with the ClariFix device significantly and clinically improves rhinitis symptoms and quality of life that are durable through 24 months after treatment.a Therefore, CPT code 31299 performed on 12/22/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for prescription fenofibric capsules 135 mg, two pills daily.  The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request medication dosage is not medically necessary for treatment of the patients medical condition. Based on the records provided, the patient presents with hyperlipidemia, intolerance to statin medication due to polyneuropathy, and treatment with fenofibric acid. In this circumstance, the recommended maximum dosage of fenofibric acid is 135 mg once daily, per prescribing information. Higher doses have not been adequately evaluated in the scientific literature. Moreover, the use of fibric acid derivatives is targeted mainly at treatment of high triglycerides and low HDL, neither of which are significantly present on the patients lipid profile while taking the current dose of fenofibric acid 135 mg one tablet daily. Current guidelines on the evaluation and management of dyslipidemia do not recommend fenofibric acid doses more than 135 mg once daily for the treatment of dyslipidemia. Therefore, fenofibric capsules 135 mg, twice daily is not medically necessary for treatment of the patients medical condition. 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being diffusely dense. It is specifically those patients who have 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. Therefore, the breast tomosynthesis performed on 1/19/16 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 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. SI joint syndrome can cause various symptoms and may be a reason for persistent low back pain, especially in patients with prior spinal fusions. If conservative treatments fail to improve symptoms, arthrodesis surgery can be considered. Minimally invasive approaches provide a good alternative to conventional methods. A triangular implant system can be used without bone grafting or screw fixation to achieve an optimal fusion of the SI joint.  Minimally invasive surgical arthrodesis of the SI joint is known to result in significant improvement in pain and function. In this case, the left SI joint has been demonstrated to be the pain generator. This was confirmed with a SI joint injection with associated pain relief. For the reasons provided, the proposed minimally invasive surgical arthrodesis of SI joint (27279) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are 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 31-year-old female enrollee has requested authorization and coverage for Xifaxan. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees irritable bowel syndrome. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. Xifaxan is approved by the U.S. Food and Drug Administration (FDA) for the treatment of IBS. According to the study by Pimentel and colleagues, Among patients without constipation, treatment with rifaximin for two weeks provided significant relief of bloating, abdominal pain, and loose or watery stools. In addition, both the American Gastroenterological Association guideline and the American College of Gastroenterology guideline reviewed the data on the randomized controlled trials for rifaximin, and found that there was moderate evidence that it was effective. In sum, Xifaxan is supported by evidence-based literature, and the medical necessity of the requested medication has been established in this patients case. For the reasons provided, the requested medication is 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 60-year-old female enrollee has requested reimbursement for DecisionDX Melanoma gene expression assay performed on 12/23/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found a commercial gene expression profile test (DecisionDX Melanoma gene expression assay has been developed in patients with stage I and II cutaneous melanoma. However, there are no 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. The National Comprehensive Cancer Network (NCCN) Guidelines, recognize that there is growing interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis. However, the routine (baseline) genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study (trial). Therefore, the DecisionDX Melanoma gene expression assay performed on 12/23/15 was not likely to be more efficacious than available standard therapy for evaluation of 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 20 year-old male enrollee has requested reimbursement for psychiatric acute inpatient treatment from 11/17/18 through 11/29/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 3 due to a lack of current suicidal ideation but a history of this as his presenting issue. With regards to functional status, the records support a score of 2 due to overall good daily function while on the inpatient unit. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to a history of substance use and commitment to sobriety as well as no active significant medical issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to some apparent peer relationship issues. In terms of level of support of the recovery environment, the records support a score of 2 due to a sober living environment and support of parents. With regards to treatment and recovery history, the records support a score of 2 due to positive response to inpatient treatment. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment and noted current insight into the need for treatment. Thus, the patient has a composite score of 15. This score correlates with community-based services. Therefore, psychiatric acute inpatient treatment from 11/17/18 through 11/29/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 19-year-old female with recurrent headaches, lock jaw, body stiffness, dizziness, as well as complaints of numbness in her legs and feet. She was treated for possible Lyme disease per the documentation. Her symptoms persisted despite this treatment. The provider noted the patients presentation required further investigation for vector-borne disease and rheumatoid diseases. The patient has requested reimbursement for infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and methylenetetrahydrofolate reductase (MTHFR) inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. Standard testing is recommended by Centers for Disease Control and Prevention (CDC) guidelines for Lyme disease, Babesia and well as Bartonella (Moore, et al). The provider noted concern was for vector-borne illnesses. The sensitivity and specificity for standard testing is appropriate for this patients constellation of symptoms. Thus, additional evaluation with polymerase chain reaction (PCR) or MTHFR testing was not indicated. Accordingly, the infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and MTHFR inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17 were not likely to be more beneficial for the evaluation of the patients medical condition as compared to standard approaches.   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 patient is a 16-year-old female with posttraumatic stress disorder (PTSD), as well as alcohol, cannabis, sedative/hypnotic/anxiolytic, psilocybin, and LSD use disorders, as well as a history of self-harm. The patientas parent has requested reimbursement and prospective authorization and coverage for intensive outpatient mental health treatment provided from 4/24/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. The physician reviewer found that The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 3. The records noted significant risk of harm, due to continued self-harm, even after months of IOP treatment. With regard to functional status, the records support a score of 3. The patient had moderate functional impairment, due to interpersonal conflict with parents and struggles to focus during online school.  In terms of comorbidity, the records support a score of 3. The patient had significant comorbidity, due to recent substance use as well as post-traumatic stress disorder, with decline in substance use while participating in the increased structure of the IOP. With regard to recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to social isolation of shelter-in place, conflict with parents, struggles with school, and potential exposure to the sisteras substance use in the home. Environmental support is scored at 2 due to the parentsa participation in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient was able to maintain abstinence from substance use while at the IOP. However, she has continued to struggle with trauma-related symptoms and self-harm. In terms of treatment acceptance and engagement, the records support a score of 2. The patient participated in treatment, with some struggles in fully implementing the strategies learned. Thus, the total CALOCUS score is 18. In this case, the recommended level of care is level three: high-intensity community-based services. This is consistent with the IOP level of care that patient has been receiving. Therefore, intensive outpatient mental health treatment provided from 4/24/20 forward was and is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 55-year-old male with a history of autoimmune hearing loss in the left ear. The patient was doing well with intermittent steroids. According to the medical records, the patient is becoming intolerant to steroids. He is having problems with shortness of breath. The patient tried treatment with the tumor necrosis factor (TNF) blocker Simponi with reported improvement in his hearing. The patient has requested authorization and coverage for Simponi 50 mg injections once per month for one year (J1602). The Health Insurer has denied this request indicating that the requested medication is considered investigational. Currently, the medical literature supports the use of steroids for treatment of autoimmune hearing loss. However, other medications, including TNF blockers and autoimmune agents, are not considered first-line therapies. The articles provided by the treating provider cite a five patient trial and admit further studies are needed. Moreover, the patients were not followed long enough for adequate assessment. Given these findings, the requested Simponi 50 mg injections once per month for one year (J1602) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested medication is 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: Overturned

Summary Reviewer 3


A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule. The physician reviewer found that electromagnetic navigational biopsy is a procedure which allows the provider to direct a biopsy forceps or brush with greater accuracy to sample lung nodules.  Existing techniques, like a standard bronchial brush or biopsy, have a low yield for peripheral lesions.  This patient had a peripheral lung lesion and hemoptysis.  Computed tomography (CT) guided needle biopsy involves a risk of bleeding.  The use of electromagnetic navigational localization allows the provider to sample a lesion with much more accuracy and safety than standard procedures.  In sum, electromagnetic navigational bronchoscopy performed on 9/29/15 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.