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

Summary Reviewer

The patient is a 57-year-old female with severe osteoporosis. As part of the work-up her endocrinologist ordered a parathyroid scan to rule out a parathyroid adenoma. The patient has requested authorization and coverage for parathyroid planar imaging. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary. The records provided for review indicate that this patient has severe osteoporosis and further evaluation for a parathyroid adenoma (primary hyperparathyroidism) is appropriate. However, the medical literature suggests that the diagnosis should be made with biochemical markers showing the combination of hypercalcemia and an elevated or inappropriately normal parathyroid hormone (PTH) level. Measured total serum calcium should be adjusted for albumin. If the corrected serum calcium is normal and PTH is elevated, serum ionized calcium should be measured, as primary hyperparathyroidism can present with an elevated ionized calcium despite a normal albumin-adjusted serum calcium (Khan, et al). The standards of care also indicate that parathyroid scan is appropriate when a decision to remove a parathyroid adenoma has been made (Khan, et al; Bilezikian, et al; Pallan, et al). Overall, parathyroid imaging is not a diagnostic procedure and is not advised unless surgical intervention is planned. The value of imaging rests with accurate identification of abnormal parathyroid tissue in order to assist in planning the appropriate parathyroid surgery (Khan, et al). In this case the diagnosis of primary hyperparathyroidism has not been established. The laboratory tests performed on 10/26/17 show normal calcium, mid-normal intact PTH level at 36 and normal ionized calcium and phosphorus. The patients 25 vitamin D and 1, 5 vitamin D levels are normal, and urinary calcium is normal. In January 2018, the patient had two normal calcium levels and intact PTH. As the patient does not have biochemical evidence of primary hyperparathyroidism, the requested parathyroid planar imaging is not medically necessary for evaluation of this patients medical condition.  Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment from 5/21/14 forward.  The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions.] The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  Considering that the patient had failed treatment in a less restrictive setting and was engaging in increasingly concerning activity, placement at the residential level of care was initially indicated as the services were reasonably expected to improve her condition at the time, and prevent a more serious episode of illness.  However, the record does not justify the medical necessity of ongoing treatment at the residential level of care from 11/01/14 forward.  The diagnosis of mood disorder, not otherwise specified has not been refined or updated.  There has been no change to the medication regimen which infers an element of clinical stability.  During the family session on 10/27/14, the unit addressed reality and expectation in a healthy manner.  Prior to that appointment, the patient successfully completed a three-day adventure therapy trip.  On 10/31/14, during the individual therapy session, the patient was able to show empathy and acceptance for an unexpected interruption.  Considering the positive clinical trend in the medical records coupled with community practice standards and current practice guidelines, residential treatment services from 5/21/14 through 10/31/14 were medically necessary for treatment of the patients medical condition.  However, services from 11/1/14 onward were not and are not medically necessary based on the documentation provided.  Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 46-year-old female enrollee has requested reimbursement for substance use residential treatment provided from 6/07/18 through 6/24/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. 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 2 due to a lack of current suicidal ideation with active intent or plan. The records noted that the patient had passive suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level in treatment but consideration of functional problems when in the community and using substances. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and history of mood symptoms. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with roommates. In terms of level of support of the recovery environment, the records support a score of 2 due to overall supportive recovery environment. With regards to treatment and recovery history, the records support a score of 3 due to current motivation for treatment but unclear response to treatment in the past. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 16. This correlates with low-intensity community-based services. Therefore, residential treatment was not medically indicated. In sum, substance use residential treatment provided from 6/07/18 through 6/25/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 59-year-old male enrollee has requested reimbursement for gene testing performed on 3/9/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15 % of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick et al). For the reasons provided above, the services at issue were 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 58-year-old female enrollee has requested authorization and coverage for breast magnetic resonance imaging (MRI). The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollee, who is status post breast implant placement. The physician reviewer found that according to the American College of Radiology appropriateness criteria, in a patient with average risk for breast cancer, or less than 15% lifetime risk, mammography or breast tomosynthesis is the appropriate screening examination regardless of the presence of breast implants. In the absence of additional risk factors, MRI is not indicated in this setting. There are specific mammographic techniques that are utilized, such as the Eklund maneuver, to displace the implant away from the breast tissue during mammography for better visualization of the breast tissue. If implant rupture is a concern, then non-contrast MRI would be indicated to evaluate for implant integrity. Alternatively, if the patient has implant rupture with free silicone in the breast, this could obscure findings on mammography, and contrast enhanced MRI may be indicated. However, there is no indication of either of these scenarios in the clinical records. In this case, breast MRI is not indicated for breast cancer screening. Specialized techniques exist for mammographic visualization of the breast tissue in the augmented breast. Thus, the requested breast MRI is not medically necessary for the evaluation of this patient. Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a 10-year-old male enrollee has requested reimbursement for the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the superior efficacy of the device at issue in this clinical setting. Murphy and colleagues noted, Following the acute phase of acute flaccid myelitis (AFM), patients typically have substantial residual disability and unique long-term rehabilitation needs." Per the authors, Patients engaged in multimodal rehabilitation can achieve functional improvements for years even after recovery of motor strength plateaus. The authors describe that potential long-term sequelae from AFM include musculoskeletal problems and psychological sequelae, such as anxiety and depression. Melicosta and colleagues reported on the rehabilitation outcomes of a cohort of 31 children with AFM who received Activity Based Restorative Therapy (ABRT), including functional electrical stimulation. The authors concluded, Children with flaccid paralysis due to AFM undergoing structured, comprehensive rehabilitation interventions, even when these are initiated long after paralysis onset, can make significant neurologic and functional gains. Recovery of function and prevention of comorbidities are the main therapeutic targets for interventions in this population. Therefore, the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested authorization and coverage for rizatriptan tablets 5 mg, 12 tablets per copayment every 30 days. The Health Insurer has denied this request and reported that the requested medication quantity is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity. This patient has been diagnosed with migraine headaches. She has tried other forms of therapy, including Topamax, gabapentin, nortriptyline, Lexapro, Wellbutrin, and Geodon. Rizatriptan is a medication that can be prescribed such that a patient may not take more than 30 mg in a 24-hour period. The dosage provided by the provider appears to be appropriate to treat three to four migraine attacks per month. This is consistent with the current standard of care. Therefore, rizatriptan tablets 5 mg, 12 tablets per copayment every 30 days is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2
A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that ongoing Botox treatment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with a long history of migraine headaches dating to childhood. The records indicate that before starting Botox she had a baseline headache frequency of 16 to 24 per month, which is consistent with the diagnosis of chronic migraine. In addition, the patient has had a marked improvement documented with Botox treatments for more than 10 years. In sum, Botox treatment for chronic migraine is indicated for this patient and ongoing treatments are 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: Experimental
Decision: Upheld

Summary Reviewer 3



A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the infliximab antibody testing performed on 3/30/15 was likely to be more effective for this patient than other available treatment options. Maximizing the efficacy of therapies for inflammatory bowel disease such as ulcerative colitis, while minimizing their toxicity remains the principal objective in developing management strategies. The loss of response to infliximab can be due to sub-therapeutic infliximab levels or the presence of antibodies to infliximab and performing this assay can be very useful in the management of the patients who are being treated with infliximab. In this case, the patient had a recent flare-up while being treated with Remicade and the infliximab antibody testing performed was indicated to assist with managing treatment strategies. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort.  The physician reviewer found the use of food-specific IgG level testing has not been shown to improve health outcomes at long-term follow-up. There is data suggesting that this testing does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods (Beyer and Teuber). Thus, food-specific IgG should not be used as a tool to diagnose food allergy and the positive foods should not be eliminated from the diet based upon results of these tests (Lemon-Mule, et al; Savilahti, et al). The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens including egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95% predictive accuracy. In conclusion, the IgG food laboratory testing performed on 2/10/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard of care.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 63-year-old male enrollee has requested reimbursement for Guardant360 liquid biopsy test performed on 9/14/20. 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 Guardant assay is a multigene assay that looks at cell-free DNA in the blood, presumably shed by cancer cells. In certain situations, where tissue biopsy is not feasible or safe, it can be used instead of a tissue biopsy assay. The hope with this and other similar assays is that they will identify a molecular target at which a therapeutic drug can be aimed to produce a clinically beneficial outcome. Thus far, however, the assay has not been shown to yield reliable and clinically useful results. A randomized study by Le Tourneau and colleagues did not demonstrate advantage to treating based on such an assay versus conventional judgment. Therefore, Guardant360 liquid biopsy test performed on 9/14/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

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 there is sufficient support for the service at issue in this clinical setting. This patient had already failed optimal medical therapy. The alternative treatment, surgical neurectomy, is well-known to be associated with increased adverse events and complications. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of chronic rhinitis with cryotherapeutic ablation of the posterior nasal nerves utilizing the ClariFix device. 

A multicenter, prospective, single-arm clinical study by Ow and colleagues showed that cryotherapy significantly and clinically improves rhinitis symptoms and quality of life with outcomes that are durable through 24 months after treatment. The prospective multicenter study by Chang and colleagues demonstrated the Reflective Total Nasal Symptom Score (rTNSS) significantly improved over pretreatment baseline at 1 month, 3 months, 6 months, and 9 months post-procedure. Gerka Stuyt and colleagues performed a prospective single-arm trial at multiple locations within a large health maintenance organization of patients with chronic rhinitis that failed medical therapy and were treated with in-office cryoablation of the posterior nasal nerve (PNN). The authors noted that the Total Nasal Symptom Score (TNSS) 12-hour symptom score significantly improved at 30 days, at 90 days and at one-year post treatment. Therefore, CPT code 31299 performed on 12/22/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 40-year-old male enrollee has requested reimbursement for acupuncture services (CPT code 97810) provided from 8/13/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees abdominal pain. The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of objective measurable evidence of functional gain and/or improvement. There are a lack of clinical references to objective functional improvement during the dates in dispute. In sum, the records lacked sufficient evidence supporting treatment with acupuncture was 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 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.