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

Summary Reviewer  
The patient is a 57-year-old male with plaque psoriasis and psoriatic arthritis and a history of end 
stage renal failure status post kidney transplant. The patient has requested authorization and 
coverage for Otezla 30 mg tablets, taken twice daily. The Health Insurer has denied this request 
and reported that the requested medication is not medically necessary for the treatment of this 
patient. This denial is the subject of this appeal and determination. The physician reviewer found 
that the submitted documentation supports the medical necessity of the requested medication. 
Takamura and colleagues report that combination therapy of apremilast and biologics could be a 
safe, effective option for the management of patients with psoriasis showing biologic fatigue. In 
this case, the patient is out of other treatment options as interleukin-23 (IL-23) inhibitors do not 
work well for arthritis, and the records note that the patient has had recurrent infections on other 
biologics. Otezla does not carry an infection risk. Given that the patient has failed all other 
conventional therapy, has numerous comorbid issues, and as the records document that he has been 
stable on the current combination of apremilast and ustekinumab, the requested medication is 
medically indicated. Therefore, Otezla 30 mg tablets, taken twice daily, are medically necessary 
for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 39-year-old male enrollee has requested authorization and coverage for corticotropin (H.P. Acthar Gel) injections, up to 40 units. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the requested medication is not considered the standard of care for this patient. The 2015 American College of Rheumatology (ACR) guidelines recommended methotrexate with or without a tumor necrosis factor inhibitor as the next treatment in those who have failed methotrexate alone. There are also multiple studies demonstrating efficacy and safety of tumor necrosis factor inhibitors in treating moderate to severe rheumatoid arthritis. In this case, there is no documentation of failure of first-line therapy as recommended by the ACR or contraindication to such trials. There is evidence that a second tumor necrosis factor inhibitor is effective in those who have tried and failed a previous tumor necrosis factor inhibitor or have had adverse reactions to another tumor necrosis factor inhibitor. There is a lack of support for the use of corticotropin (H.P. Acthar Gel) injections in this clinical setting. The medical records note that the patient has been on H.P. Acthar Gel for greater than one year. Use beyond an acute exacerbation is not within the U.S. Food and Drug Administration (FDA) indication. In sum, corticotropin (H.P. Acthar Gel) injections, up to 40 units is not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 44-year-old transgender male who has documented gender dysphoria. The patient has requested authorization and coverage for CPT codes 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk), 54660 (insertion of testicular prosthesis), 55180 (scrotoplasty; complicated) and 14040 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 square cm or less). 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 World Professional Association for Transgender Health (WPATH) states that scrotoplasty and testicular implants, as well as phalloplasty in general, are medically necessary treatments for gender dysphoria. WPATHas position statement notes, aIn addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the standards of care. These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient.a Coleman and colleagues noted that for treatment of gender dysphoria, phalloplasty includes, aa pedicled or free vascularized flap, vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses.a The current medical evidence supports the requested services in this clinical setting. Therefore, CPT codes 15734 (muscle, myocutaneous, or fasciocutaneous flap; trunk), 54660 (insertion of testicular prosthesis), 55180 (scrotoplasty; complicated) and 14040 (adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 square cm or less) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 12-year-old male enrollee has requested authorization and coverage for Otezla (Apremilast Tab Starter Therapy Pack 10 MG & 20 MG & 30 MG). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Apremilast is a phosphodiesterase-4 inhibitor that has been U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis. It targets the inflammatory cascade at an earlier point in time to have a broader pro-inflammatory response target. This medication has a low side effect profile and is well-tolerated by patients. It is particularly useful for patients who have failed other treatments because of side effects or lack of efficacy. It has been successfully used in adolescents, but is not yet FDA approved for that population. The problem with tumor necrosis factor inhibitor medications, such as Enbrel and Humira, is that patients are at significant risk of infection. Those particularly susceptible are individuals with chronic or recurrent infections. This patient has been diagnosed with post-infectious encephalopathy and has a history of recurrent infections that have exacerbated his neuropsychiatric symptoms. In this particular case, use of apremilast is medically necessary and appropriate. Therefore, Otezla (apremilast tablets starter therapy pack 10 mg and 20 mg and 30 mg) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 56-year-old male enrollee has requested reimbursement for ipilimumab (J9228) and pembrolizumab (J9271) injections administered on 7/19/16 and 9/13/16. The Health Insurer has denied this request indicating that the medications at issue were not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that there is a lack of support in the medical literature for the medications at issue used in this clinical setting. Ipilimumab and pembrolizumab are not considered a standard treatment for prostate cancer either systemically or as localized therapy. They are not U.S. Food and Drug Administration approved and are not supported by major drug compendia or the medical literature. Yervoy and Keytruda are the ongoing subject of clinical trials that have not yet reached beyond phase I and II trials. As such, ipilimumab (J9228) and pembrolizumab (J9271) injections administered on 7/19/16 and 9/13/16 were not medically necessary for the treatment of this patients medical condition. Therefore, based on the above, the medications at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). The Health Insurer has denied this request indicating that the requested service is not medically necessary for evaluation of the enrollees left-sided back pain.   The physician reviewer found that based on the findings on the 1/24/17, a repeat MRI is not medically necessary for further evaluation of this patients medical condition. If the first MRI study was inadequate due to motion, a repeat limited examination should have been performed at the original facility. However, the records provided for review do not demonstrate that the initial MRI study was inadequate as there is no description of artifact or inadequate imaging by the interpreting provider. Thus, the requested MRI is not supported as medically necessary. Based on the foregoing, the requested service is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 55-year-old male who initially presented with sudden sensorineural hearing loss. Subsequently, he was diagnosed with autoimmune hearing loss. He has experienced fluctuating high frequency hearing loss, tinnitus, hyperacusis, and vertigo. He has been treated with prednisone since August 2017, has been treated successfully with intratympanic Simponi 50 injections. 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. Simponi has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and ulcerative colitis. Autoimmune inner ear disorder is one of a few types of sensorineural hearing loss that is treatable and potentially reversible. Treatment involves oral steroids and methotrexate, as well as other treatment modalities with variable success rates. These treatments are systemic, with inherent side effects limiting their effectiveness. Recently, tumor necrosis factor (TNF) alpha blockers have been suggested as a modality of treatment. In one study, Simponi stabilized hearing in three of seven per-protocol patients with autoimmune hearing loss and allowed a complete tapering off of prednisone in those patients. In addition, this patient has experienced positive response to prior treatment with Simponi. Accordingly, the requested Simponi 50 mg injections once per month for one year (J1602) 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 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: Upheld

Summary Reviewer 1


A 38-year-old male enrollee has requested authorization and coverage for chemotherapy administration into the peritoneal cavity via indwelling port or catheter (hyperthermic intraperitoneal chemotherapy. 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 the use of hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis for colon cancer remains controversial. It is suspected that about 25% of patients with metastatic colorectal cancer have disease limited to the peritoneal cavity and that perhaps this represents a different entity than metastatic disease involving the liver and lungs. Studies suggest a benefit from hyperthermic intraperitoneal chemotherapy in carefully selected patients.  However, standard use remains the subject of ongoing clinical trials.  At this time, there is a need for randomized clinical trials addressing the risks and benefits associated with this modality.  At this time, the use of hyperthermic intraperitoneal chemotherapy has not been shown to be superior to standard chemotherapies for colorectal cancer.  All told, the requested services are not likely to be superior over other treatment options.  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: Overturned

Summary Reviewer 2

A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. 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 the medical evidence supports the services at issue in this clinical setting. The CxBladder test is used to rule out bladder cancer in patients with hematuria as a complement to cystoscopy. Lotan and colleagues performed a study of 803 patients undergoing surveillance for bladder cancer. The authors noted that CxBladder test had superior sensitivity and a negative predictive value compared with cytology, NMP22, and UroVysion. The use of CxBladder can potentially reduce the need for invasive diagnostic testing. All told, gene expression profiling performed on 5/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 12/18/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found 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 this case, the patients breasts were not particularly dense.  However, the records noted a cyst which had increased in size from the 1.5 cm that was previously noted in 2009, to a size approaching 5 cm.  The significant increase in size is concerning, and on occasion, breast tomosynthesis will provide significant information in terms of the contour or margination of a mass.  The increase in size is a reasonable indication for breast tomosynthesis.  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: Overturned

Summary Reviewer 


A 56-year-old female enrollee has requested authorization and coverage for Vemlidy.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees hepatitis B. The physician reviewer found that the guidlines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, Vemlidy is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 12/18/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis performed on 12/18/15 was likely to have been superior over other modalities.  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: Overturned

Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement for partial hospitalization from 8/4/16 through 8/17/16. 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 sufficient support in the medical literature for the services at issue in this clinical setting.  In general, community intervention settings offer optimization of treatment gains. However, transient placement in more restrictive settings is often clinically appropriate, as in this patients case. In this particular case, the treatment team recommended continued treatment at the partial hospital level of care. The treatment team noted that the patient did not command the skills needed to maintain weight and function with full autonomy in the outpatient setting. The treating team justified their determination within context of the partial hospital level of care guidelines developed by the American Psychiatric Association. Factors that warrant partial placement based on the assessment included patient status and environmental support, psychiatric comorbidity, preoccupation with intrusive repetitive thoughts, and the need for structure to help with weight management and dietary habits. On 8/4/16, the patient was demonstrating rigidity regarding her meal plan.  She took small bites and took five minutes to finish the final bites of a sandwich.  She was passive-aggressive in her attempts to bypass programmatic procedures and became irritated when called out. On 8/6/16, her anxiety spiked upon learning that her daughter had attempted suicide. On 8/8/16, she became panicked after the sensation of having food stuck in her esophagus, and was unable to eat afterwards.  On 8/9/16, the patient reported more intense urges to exercise and restrict her diet.  Additionally, the patients serotonergic medication was changed and benzodiazepine was reduced, while gabapentin, trazodone and atenolol were added. Considering these factors, the patient had not consolidated the treatment gains necessary to follow a meal plan and maintain a healthy weight in a less restrictive setting. She was at risk for undue morbidity and admission to a higher level of care in the absence of partial hospitalization.  The setting was safe, appropriate and consistent with good medical practice. The patient received services that were reasonably expected to improve her condition and prevent a more serious episode of illness. As such, the services at issue from 8/4/16 through 8/17/16 were consistent with community standards and afforded opportunity for aggressive medication changes and arrangement of comprehensive aftercare in her community.  Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 48-year-old female enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation from 11/23/15 forward. The Health Insurer 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 that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  First, the clinical record indicates diagnoses of posttraumatic stress disorder and bipolar disorder.  Transcranial magnetic stimulation is not indicated for these conditions.  Additionally, for those with unilateral depressive illness, the safety and utility of long-term and/or maintenance treatment with transcranial magnetic stimulation has not yet been established by the scientific community.  Although the American Psychiatric Association Practice Guideline for depression endorses transcranial magnetic stimulation for the acute phase treatment of major depressive disorder, it has not yet been endorsed for maintenance treatment or long-term therapy.  There are a few small studies which demonstrate positivism for maintenance therapy.  However, the statistical power and study designs render the findings inadequate to define definitive recommendations regarding the long-term use of the intervention at this time.  All told, transcranial magnetic stimulation from 11/23/15 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and 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 62-year-old male enrollee has requested reimbursement for the Life Vest provided from 6/10/15 through 7/10/15. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees dilated cardiomyopathy. The physician reviewer found that in selected patients with severe but potentially reversible cardiomyopathy, such as tachycardia or myocarditis associated cardiomyopathy, a wearable cardioverter defibrillator may be indicated. There is adequate data demonstrating the wearable cardioverter defibrillator may be useful for the prevention of sudden cardiac death due to ventricular arrhythmias while awaiting improvement in left ventricular function, implantable cardioverter defibrillator implantation, or if needed, cardiac transplantation. Given this patients severe left ventricular dysfunction and non-sustained ventricular tachycardia, it was reasonable to place the Life Vest while awaiting the recovery of the heart function. Thus, the Life Vest provided from 6/10/15 through 7/10/15 was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.