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

Summary Reviewer 

The patient is a 16-year-old male who underwent surgery on 7/02/19 for management of recurrent dislocation of patella with medial patellofemoral ligament tear, and associated chondromalacia and loose bodies. The procedures included left knee arthroscopy with patellofemoral chondroplasty, excision of loose bodies, tibial osteotomy and patellofemoral ligament reconstruction with allograft. The physician reviewer found that intermittent pneumatic compression is now a widely used therapy for the prophylaxis of deep vein thrombosis and pulmonary embolism, particularly after major surgical procedures on the lower extremities with prolonged immobilization. In general, the device sequence is composed of sequential compression and deflation. Typically, veins are considered to be emptied during the compression phase and refilled during the deflation phase. The device may be supplemented with pharmacotherapy for optimum deep vein thrombosis prophylaxis. In this case, the patient was not able to ambulate for almost nine weeks, and there was a clear need for deep vein thrombosis prophylaxis. As such, the intermittent limb compression device was medically appropriate. Therefore, the intermittent limb compression device provided on 7/02/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 26-year-old male enrollee has requested reimbursement for substance use partial hospitalization services provided from 9/14/18 through 10/04/18. 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 1 due to a lack of current suicidal ideation and no self-harming behaviors. With regards to functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and controlled depression and anxiety symptoms. With regards to level of stress of the recovery environment, the records support a score of 3 due to no mention of a stressful recovery environment. In terms of level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. With regards to treatment and recovery history, the records support a score of 3 due to success in the partial hospitalization program with a good level of cooperation and maintenance of sobriety. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into his need for treatment. Thus, the patient has a composite score of 15. This score is consistent with a community-based outpatient clinic setting. Therefore, substance use partial hospitalization services from 9/14/18 through 10/04/18 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The representative of a 63-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 5/23/16 through 6/23/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. Considering the patients clinical condition and relevant history, and the potential for a complicated alcohol withdrawal syndrome, acute hospitalization represented a safe and appropriate intervention at the time of presentation. However, the record does not support the medical necessity of the setting as of 6/2/16. The patient was admitted on an alcohol detoxification protocol and was engaged in active treatment. He completed a benzodiazepine taper on 5/26/17.  The following day he was pleasant with no signs of alcohol withdrawal. The patient had his antidepressant medication, escitalopram, increased by 50% on 5/26/17 and then again to the maximum dose on 5/30/17.  He was sleeping well on a conservative dose of trazodone at nighttime.  He was adherent with his medications and had no side effects.  On 5/31/17, the patient was less tense, less confused and more relaxed.  He was eating 75 to 100% of his meals.  Although, he was isolative and labile at times, he was not disruptive on the unit.  He had no suicidality, homicidal ideation, agitated behavior or psychosis.  On 6/1/17, the patient was stable for discharge, which was planned for the next day.  However, an issue related to the power of attorney derailed the discharge.  In sum, the admission improved the patients clinical condition and more than likely prevented a more serious episode of illness.  During the course of the hospitalization, although mildly depressed in context of chronic cognitive decline, the patients acute syndrome resolved.  He was not psychotic.  He was not aggressive.  He was neither suicidal nor homicidal.  He was responding well to psychotropic medication.  He successfully completed supervised alcohol detoxification.  Continued specialty care remained indicated to capitalize on the therapeutic momentum, but there was no indication that service delivery in a less restrictive setting would have been unsafe or inadequate from 6/1/16 forward. Thus, a portion of the services at issue were medically necessary. Specifically, the mental health inpatient treatment from 5/23/16 through 6/1/16 were medically necessary, but not thereafter. Therefore, for the reasons stated above, a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 24-year-old female with symptoms of plantar hyperhidrosis. Her past medical history is significant for bilateral thorascopic sympathectomy for severe palmar hyperhidrosis in 2013. The patient has attempted medical management of her condition with over the counter therapy agents such as Drysol and Robinul Forte.  She reported that this condition limits her ability to function and interferes with her social life. The patient has requested reimbursement and prospective authorization and coverage for sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17. The Health Insurer has denied this request and reported that the services at issue were and are investigational for the treatment of this patient. In recent years, lumbar sympathectomy has been proposed for treatment of patients with intractable palmoplantar hyperhidrosis.  To date, the amount of long term, prospective evidence addressing the use of lumbar sympathectomy for the treatment of plantar hyperhidrosis is limited.  Questions about efficacy, side effects and long-term outcomes have yet to be answered.  Since a formal protocol/technique does not yet exist for this novel technique, the level at which surgeons perform their lumbar sympathectomy is controversial and may vary among institutions. For this reason, higher rates of complications are associated with lumbar sympathectomy than alternative treatments for hyperhidrosis.  The evidence addressing the use of lumbar sympathectomy is insufficient, to date, to allow an adequate evaluation of safety and efficacy. Thus, the superior efficacy of sympathectomy performed by an out-of-network provider from 2/09/17 through 5/10/17 has not been established.  Based upon the information set forth above, the services at issue were not and 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 patient is a 72-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland, with disease recurrence in his left internal iliac nodal chain. The patient has requested authorization and coverage for robotic stereotactic body radiation therapy. 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 submitted documentation supports the medical necessity of the requested services in this clinical setting. Aggressive local treatment of oligometastatic disease has been associated with improvement in survival. This patient has locoregionally-confined disease, which is technically curable. He would not be a great candidate for salvage surgery, given the prior operation and likely presence of extensive adhesions. Furthermore, systemic therapy would not be a curable treatment option. External beam radiotherapy (in the form of intensity modulated radiation therapy or stereotactic body radiation therapy) represents his best chance for cure. In this setting, stereotactic body radiation therapy is supported by the National Comprehensive Cancer Network (NCCN) guidelines as well as the American Society for Radiation Oncology (ASTRO) Model Policy. Therefore, robotic stereotactic body radiation therapy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 21-year-old male, who is under evaluation and management for gastroesophageal reflux disease (GERD). The patient has been treated with lansoprazole and pantoprazole. A recent upper endoscopy was normal, except for an irregular Z-line. The patient underwent a 96-hour esophageal power of hydrogen study and had a low prevalence of acidic reflux on each of the days. There are no episodes of long reflux. An esophagram confirmed the absence of a hiatal hernia. 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. According to the documentation submitted for review, there is a lack of evidence demonstrating the patient has a very low percentage acid exposure time (AET) of the esophagus, with very brief reflux episodes. In addition, in a young male patient, especially with refractory GERD symptoms, biopsies of the proximal and distal esophagus should be done to rule out eosinophilic esophagitis. The records do not indicate that these biopsies have been completed. Therefore, based on the clinical record, the request for 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.  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 upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 46-year-old female enrollee has requested authorization and coverage for ketamine infusion and one day inpatient stay. The Health Insurer has denied this request indicating that the requested services are considered experimental/investigational for treatment of the enrollees peripheral neuropathy status post chemotherapy treatment. The physician reviewer found the requested services are not likely to be more effective for this patient than other available treatment options. There is insufficient evidence in the peer-reviewed literature to support the use of ketamine for the treatment of neuropathic pain conditions. Moreover, the safety of long-term use of ketamine has also not been established. Therefore, ketamine infusion is not likely to be more beneficial for treatment of the patients neuropathic pain than other available standard treatments. 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 43-year-old enrollee has requested reimbursement and prospective authorization and coverage for tobramycin/betamethasone/itraconazole compound from 7/25/16 and 8/3/16 and forward. The Health Insurer has denied this request indicating that the compounded medications were and are considered investigational for treatment of the enrollees chronic sinusitis. The physician reviewer found that there is a lack of evidence in the medical literature to support the superior efficacy of the compounded medications at issue in this clinical setting. While the use of budesonide in a nebulized form in treatment of chronic otherwise refractory rhinosinusitis has gained some acceptance, its use, as well as the use of steroids compounded with antibiotics and/or antifungal medication is off label and unproven in efficacy. There is very limited clinical data to support its superiority over standard forms of therapy. All told, in light of the limited clinical evidence in the literature, tobramycin/betamethasone/itraconazole compound administered on 7/25/16 and 8/3/16, forward was not, and is not likely to be more effective than the standard therapies available for treatment of this patients medical condition. Therefore, for the reasons stated above, the compounded medications were not and are not likely to have been 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: Upheld

Summary Reviewer 2

A 50-year-old male has requested authorization and coverage for code 43210 and one inpatient bed day. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. This patient does not have pathologic acid reflux by testing, and the records do not support a reflux operation or procedure. Transoral incisionless fundoplication (TIF) is an endoscopic procedure performed under general anesthesia. TIF can be performed in patients with typical gastroesophageal reflux disease symptoms, no or only low-grade erosive esophagitis (grades A and B), and no or only small hiatal hernia (less than or equal to 2 cm). Although TIF is associated with fewer postoperative adverse effects, such as gas, bloating and dysphagia, compared with surgery fundoplication, the durability of TIF is less than that of surgery. Huang and colleagues performed a meta-analysis of five randomized trials and 13 prospective studies. The authors noted that proton pump inhibitor use after TIF increased over time, and the satisfaction rate was only 69.15% at six months. In sum, code 43210 and one inpatient bed day are not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 12-year-old male enrollee has requested authorization and coverage for growth hormone therapy. 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 fails to establish the medical necessity of the requested services. According to the documentation submitted for review, the patients height is not more than 2 standard deviations below normal for age and gender, his growth velocity is within normal limits, IGF-1 is normal, and peak GH response to provocative testing is normal. Thus, the patient does not have auxological or biochemical criteria for GH deficiency. The delayed bone age and small anterior pituitary gland without evidence of midline defects or other pituitary deficiencies is most consistent with a diagnosis of constitutional delay rather than GH deficiency. The adult predicted height based on a bone age of 10 years and height measurement of 133.4 cm in 9/8/14 is 64.7 inches, not short enough to warrant a trial of GH therapy for idiopathic short stature based on U.S. Food and Drug Administration criteria. Based on the medical literature cited above and the documentation submitted for review, the requested services are not medically necessary for treatment of the patients medical condition.Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 64-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 8/14/19. 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 Melanoma is a cancer that is curable in its earliest stages. Cutaneous 
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for 
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha. The data on 
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the 
treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma 
testing performed on 8/14/19 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 45-year-old male with a diagnosis of amyotrophic lateral sclerosis (ALS). The patient initially presented in 2013 with right hand cramps and weakness. Nerve conduction studies showed denervation and chronic lower motor neuron changes in the left cervical, left lumbosacral, trapezius and thoracic paraspinal muscles. The patient has requested authorization and coverage for edaravone (Radicava). The Health Insurer has denied this request as investigational. Radicava is a free radical scavenger that slows the functional deterioration in some patients with ALS. Radicava is U.S. Food and Drug Administration (FDA) approved for patients ALS without any restriction to the variant or severity of ALS. There is evidence for the benefit of Radicava in patients with early ALS which suggests Radicava would also benefit the greater ALS population. Therefore, the request for Radicava 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 medication is 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 3

A 49-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 3/15/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who underwent a breast screening evaluation. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In very recent years, there have been several studies that have supported the use of breast tomosynthesis as a more accurate study than routine screening mammography. As noted by 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. Friedewald and colleagues noted the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. In this case, this patients breasts have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed on 3/15/17 was likely to have been more effective than 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: Upheld

Summary Reviewer 3

A 55-year-old female enrollee has requested authorization and coverage for corticotropin (Acthar Gel). The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with rheumatoid arthritis and has been treated with multiple medications, including anti-inflammatory drugs (NSAIDs), high-dose intravenous corticosteroids, methotrexate, Arava, Xeljanz, Actemra, and Orencia. Per the treating provider, she has developed either side effects to the tried medications or has not responded sufficiently in terms of disease activity to the medications. Acthar Gel is not a recommended treatment for rheumatoid arthritis. Furthermore, there is a paucity of objective data to support that the patient has had an inadequate response to other evidenced-based medications that have been tried previously. Per the last included treatment note from September 2019, objective findings included synovitis at one joint that was chronic, and no significant deformities of any joint. The submitted documentation fails to support the requested medication in this clinical setting. Thus, corticotropin (Acthar Gel) is not likely to be more beneficial than other treatment options.