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

Summary Reviewer 3

A 53-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 3/11/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   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. However, in this particular patient, there were no problems to be resolved, the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. Thus, a routine mammogram would have been sufficient for evaluation of the patients risk for breast cancer. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms. Given these findings, the breast tomosynthesis performed on 3/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard imaging technique.  Based upon the information set forth above, the diagnostic procedure 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 2

A 58-year-old male enrollee has requested authorization and coverage for intravenous immune globulin. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees myasthenia gravis. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. There are several reports of non-controlled studies which demonstrated a benefit from the use of intravenous immune globulin in some patients with myasthenia gravis as a maintenance therapy. In this case, the patient developed severe myasthenia gravis that failed to respond to several immunosuppressive drugs. The patient has been stable while on intravenous immunoglobulin. In sum, intravenous immune globulin is likely to be superior over other treatment options in this patients case. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 13-year-old female enrollee has requested reimbursement for emergency medical services provided on 8/02/18. The Health Insurer has denied this request and reported that the services at issue were not required on an emergent basis. The physician reviewer found that this patient presented after a wick, which had been placed following abscess drainage, fell out. The patients mother was concerned that an abscess was re-developing. In most cases, following an incision and drainage of an uncomplicated skin abscess with a wick left in place, the patient is advised to return for packing removal. The patient presented on a Thursday morning. She had no fever or other sign of systemic infection. Her vital signs were normal. The infection had not suddenly worsened or spread. Although the patient may have warranted medical attention, this care could safely have been provided on a non-emergent basis. A patient who has already undergone abscess incision and drainage with recurrent swelling at the site without fever does not meet prudent layperson criteria for an emergency. A prudent layperson in these circumstances would not reasonably expect the absence of emergency care to jeopardize ones health. Therefore, this patients symptoms on 8/02/18 did not meet prudent layperson criteria for emergency care.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 45-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma. The physician reviewer found that guidelines for asthma treatment recommend inhaled steroids as first line of therapy for patients with persistent asthma. The patients provider recommends bronchial thermoplasty because the patient has not been able to tolerate standard therapies to treat his medical condition. Moreover, per the records, inhaled steroids may trigger the patients depression. However, studies which demonstrate a link between depression and the use of inhaled steroids are lacking. The amount of steroids which gets into the circulation is very small, and it is unlikely to trigger depression. Also, there are methods to decrease intestinal absorption of inhaled steroids. In sum, this patient has not demonstrated that he has tried and failed standard medications recommended in the asthma guidelines. For these reasons, the requested procedure is not likely to be more efficacious for treatment of this patients medical condition than other alternatives. Based upon the information set forth above, the requested procedure 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 2 
A 44-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral on 7/6/21. The Health Insurer has denied 
this request and reported that the service at issue was investigational for the treatment of the 
enrollees bilateral chronic eustachian tube dysfunction. The physician reviewer found that the 
standard medical therapies for the treatment of eustachian tube dysfunction include a trial of 
intranasal steroid therapy and/or oral glucocorticoids. The most widely accepted standard surgical 
treatment for eustachian tube dysfunction is myringotomy, with or without tube insertion, regarded 
as relatively safe and effective. While Poe and colleagues along with Meyer and colleagues appear 
to demonstrate a statistically significant benefit of balloon dilation of the eustachian tube over 
intranasal steroids and/or oral glucocorticoids, these studies were both limited by small patient 
pools, lack of blinding, loss to follow up, and a large enough degree of crossover of patients from 
the control arm to the treatment arm midway through the studies that neither study was able to 
compare the treatment and control groups at the final follow up. In a study of outcomes through 
52 weeks, Anand and colleagues suggested that the beneficial effects of balloon dilation of the 
eustachian tube and medical management on tympanogram normalization and symptoms of 
subjects  with  refractory  obstructive  eustachian  tube  dysfunction  demonstrated  significant 
durability. There is less data available comparing balloon dilation of the eustachian tube with 
myringotomy, with or without tube insertion. In a cohort study comparing balloon dilation of the 
eustachian tube to balloon dilation of the eustachian tube along with adjunctive myringotomy with 
tube insertion, Chen and colleagues noted a statistically significant difference in post-operative 
hearing loss between the two groups, favoring balloon dilation of the eustachian tube along with 
tube placement, but did not identify a statistically significant difference in regards to overall cure 
rate or effectiveness. Thus, while current medical literature suggests that balloon dilation of the 
eustachian tube is more efficacious than the standard medical therapies of intranasal steroids and 
oral glucocorticoids in the management of eustachian tube dysfunction, there is a lack of similar  data to suggest that it is a more effective treatment than myringotomy with or without tube 
placement. Therefore, nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon 
dilation); bilateral on 7/6/21 was not likely to have been more beneficial for treatment of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in patients case. There is a lack of evidence that this patient has Lyme disease. Late stage Lyme disease does occur, but involves the heart, joints or the central nervous system. This patient has had no arthritis or heart block and has a normal neurological examination. There is also no credible laboratory evidence she has Borrelia infection. Treatment with parenteral antibiotics is not supported by the information provided.  Thus, intravenous ceftriaxone is not likely to be of greater benefit than other treatment options. 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 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that normal surveillance for tumor recurrence for patients after radiation therapy for prostate cancer include serial serum PSA levels and digital rectal examinations. In the setting of rising PSA levels, it is necessary to determine the location and extent of the recurrent disease to guide further treatment. There are currently two FDA approved prostate-specific PET agents used in the setting of suspected recurrence, one of which is fluciclovine-18 (F-18). F-18 PET/CT has been shown to be significantly more effective than computed tomography (CT) alone. In this case of rising PSA levels in a patient with a history of prostate cancer status post radiation, multiple studies were performed, including prostate MRI and biopsies, none of which identified the site of disease recurrence. A prostate specific PET/CT examination was the next recommended test, which revealed the site of disease. Thus, PET performed on 3/08/18 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: Upheld

Summary Reviewer 


The parent of a 16-year-old transgender male enrollee has requested authorization and coverage for bilateral mastectomy. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that from the provided materials, it does not appear that appropriate or healthy transition of a psychosocial nature has occurred for the patient. Since the guidelines for surgery in adolescence are not concrete and are subject to further subjective analysis, the decision-making needs to be based on overall psychosocial adjustment. There is a lack of objective evidence in this case to recommend, with any degree of certainty, that the patient has the capacity to consent to this procedure at this time. World Professional Association for Transgender Health (WPATH) indicates that bilateral mastectomy may be appropriate when the patient has lived for ample time as the desired gender, with hormone therapy and psychosocial adjustment to the desired gender. WPATH indicates that psychotherapy should focus on reducing a childs or adolescents distress related to the gender dysphoria and on ameliorating any other psychosocial difficulties. In this case, there is no evidence that psychosocial therapy has occurred.  There are no therapy records in the supplied materials.  There is no clinical assessment of adjustment issues, whether negative or positive, by a behavioral health clinician in the form of clinical records. Thus, the requested bilateral mastectomy is not medically necessary for the treatment of this patient. Therefore, the requested procedure 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 53-year-old female enrollee has requested authorization and coverage for a powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested device in this clinical setting. Use of the myoelectric elbow-wrist-hand orthosis in chronic stroke patients with moderate and severe impairment in their upper extremities, such as this case, enables patients to use their affected upper extremities, facilitating increased function, independence and participation in valued activities inside and outside of home. Current quality evidence shows the use of the myoelectric elbow-wrist-hand orthosis increases gross manual dexterity and the quality of task performance. Moderately and severely impaired stroke survivors exhibit severely diminished ability to incorporate their affected upper extremities into daily activities and subsequently have limited treatment options. This limitation often necessitates prescription of compensatory strategies (e.g., one-handed techniques) and/or assistive devices (e.g., range of motion braces, splints) to maximize independence, with limited involvement from the paretic upper extremity. In contrast, current evidence supports that paretic arm disability may be significantly reduced while wearing a myoelectric elbow-wrist-hand orthosis, allowing for immediate use of the paretic arm and hand, with little device training. Thus, the requested powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), including microprocessor, sensors, all components and accessories, custom fabricated is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  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 the submitted documentation supports the medical necessity of a portion of the services at issue.  Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition with new onset atrial fibrillation and could have been treated at a lower level of care. At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.  Given the patients recent arrhythmia and need for anticoagulation, the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened.  Given the potential for cardiac complications, acute inpatient medical admission from 12/22/16 through 12/24/16 was medically necessary. However, inpatient hospital stay from 12/20/16 through 12/21/16 was not medically necessary for the treatment of this patient. 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: Overturned

Summary Reviewer 

The patient is a 48-year-old female who underwent bilateral mastectomies for breast cancer and deep inferior epigastric perforators (DIEP) flap and latissimus flap breast reconstruction. The patient has requested authorization and coverage for three (3) surgical days for reconstructive lymphedema surgeries. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. As noted by the provider, the lymphaticovenous anastomosis procedure will take eight hours of operative time and the free lymph node transplant will take eight hours of operative time. It is not reasonable to plan these procedures for the same operative session, as 16 hours of elective anesthesia time is not reasonable. This is an excessively long anesthesia time for a single operative session. It is not reasonable to expect a surgeon to perform a 16-hour elective procedure and anticipate optimal outcomes. The procedures are made even more complex by the patientas previous surgeries and her history of radiation therapy, raising the risk that the procedures will be even longer than the total anticipated operative time of 16 hours. Staging these procedures is medically appropriate. Therefore, three (3) surgical days for reconstructive lymphedema surgeries are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 19-year-old female enrollee has requested reimbursement for the bilateral reduction mammoplasty performed on 5/14/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bilateral macromastia.  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS), symptomatic breast hypertrophy is defined as a syndrome of persistent neck and shoulder pain, painful shoulder grooving from brassiere straps, chronic intertriginous rash of the inframammary fold, and frequent episodes of headache, backache, and neuropathies caused by heavy breasts caused by an increase in the volume and weight of breast tissue beyond normal proportions. Consistent with the guidelines from the ASPS, this patient has well-documented back, neck and shoulder pain, as well as shoulder grooving from bra straps. This patient had traditional signs and symptoms of macromastia that was likely to benefit from breast reduction. Moreover, the patient had failed conservative measures as supported by examination notes as well as detail from the operative report. Photographs were not provided for review, but based on the overall clinical picture and degree of breast tissue resected the procedure was not an aesthetic mastopexy or minimal breast reduction. As expected with the procedure, the patient has reported significant functional improvement following her breast reduction. Given these findings, the bilateral reduction mammoplasty performed on 5/14/14 was medically necessary for treatment of this patients bilateral symptomatic macromastia. Therefore, 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 3 
 
A 32-year-old female enrollee has requested authorization and coverage for a prescription for 
Qulipta  60  mg tablets. The  Health  Insurer has  denied this  request  and  reported  that  the 
requested medication is investigational for the treatment of the enrollees headaches. The 
physician reviewer found that in this case, notes dated 4/26/22 reported that the patient has an 
average of one migraine monthly around her menstrual cycle that can last up to three days. Given 
that this patients headaches are centered around her menstrual period, there is evidence of the 
evidence of efficacy of other abortive and preventative interventions including prescription drugs 
and hormonal therapy in this clinical setting. Nierenburg Hdel and colleagues report that of all 
categories of treatment for menstrual migraine, triptans have the most extensive research with 
strong evidence for both acute and preventive treatment of menstrual migraine. There is a lack 
of evidence supporting the use of Qulipta in catamenial migraines. Therefore, a prescription for 
Qulipta 60 mg tablets is not likely to be more beneficial for treatment of the patients condition 
than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 41-year-old male who was admitted to the hospital on 2/05/20 following a rollover motor vehicle accident. The patient has requested reimbursement for continuation of sub-acute level stay from 4/18/20 through 4/30/20. 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 Tibial plateau fractures are complicated injuries, each requiring an individualized initial approach, whether surgical or nonsurgical. Early mobilization and other rehabilitation interventions can be helpful in mitigating complications following these fractures, such as joint stiffness and atrophy of the muscles and bony tissues. There is, however, no consensus regarding rehabilitation practices, as immobilization and weight-bearing restriction recommendations from orthopedic surgeons vary widely. There remains a dearth of high-quality literature informing best rehabilitative practices, particularly with respect to the timing of weight-bearing allowance.  Despite surgical and rehabilitative care, these fractures can result in significant persistent impairments with respect to the knee and global functionality. In the current case, as of early to mid-April 2020, the patient had been in the inpatient rehabilitation setting for an extended period of time. He had essentially plateaued at a level where he was requiring assistance for lower body self-care and transfers. He was non-ambulatory but able to propel a wheelchair. Barriers to progress included his body habitus, pain and environmental barriers. There are no indications that he required ongoing inpatient services at the skilled nursing facility level as of 4/28/20 to 4/30/20 inclusively. He did not have skilled nursing needs or ongoing rehabilitation goals requiring inpatient care. His care during that time was custodial in nature, while he awaited re-hospitalization for further surgery. Care from 4/18/20 through 4/30/20 could have been provided in a less intensive setting of care until more intensive rehabilitation could be pursued after additional surgery and with liberalized weight-bearing restrictions. Therefore, continuation of sub-acute level stay from 4/18/20 through 4/30/20 was not medically necessary for the treatment of this patient.