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

Summary Reviewer 

A 68-year-old female enrollee has requested authorization and coverage for Repatha 140 mg/ml. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request for Repatha 140 mg/ml is medically necessary for treatment of the patients medical condition. Based on the records provided, the patient is a 68-year-old female with known coronary disease, dyslipidemia and documented inability to tolerate several statin medications. Most recently, she is treated with a maximally tolerated low intensity statin, fluvastatin once weekly. Her LDL cholesterol on the above maximally tolerated statin is not at goal and there is evidence of progression of coronary disease. Repatha (evolocumab) is a PCSK9 inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. The documentation submitted for review shows that the patients LDL is not at goal and that she has tried and did not tolerate several statins including atorvastatin, rosuvastatin and fluvastatin in addition to Zetia in combination with a statin medication. Therefore, the medical necessity for treatment with Repatha 140 mg/ml has been established in this clinical setting.  Therefore, the requested medication is 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 64-year-old male enrollee has requested reimbursement for air ambulance transport on 7/19/14 through 7/20/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the review of the submitted evidence demonstrates the patient was involved in a serious motor vehicle accident on 7/2/14, resulting in multiple life-threatening injuries and requiring air transportation to the nearest hospital for stabilization and intensive medical treatment. The patients condition initially required placement on life support with subsequent sedation and was further complicated by underlying medical problems, such as a history of prior lung cancer. Open and active communication among the members of the medical team and the family, and later with the injured person, is of significant importance in this setting in order to consistently match the medical care to the injured persons needs and goals and to maximize subsequent recovery. Further, these extensive injuries typically require prolonged and aggressive medical treatment in order to have the best possible ultimate recovery, function and speech, and ability to think clearly. According to the submitted documentation, the hospital nearest to the accident site was able to provide the technical medical skills that the patient required. However, the significant language barrier prevented the open and active communication that was necessary, and this was likely to interfere with the patients overall medical care and subsequent recovery.  Transportation to a facility that had English-speaking medical team members was therefore necessary. However, there were a number of such facilities in Italy and other nearby countries that could meet these criteria. Further, the patients overall condition at the time of the transfer was somewhat tenuous. Shorter transportation time may have placed less physical stress on the body while in this state and would have also returned the patient to a more controlled intensive medical environment faster. For these reasons, air ambulance transportation from Pisa, Italy to the receiving hospital in California was not medically necessary. For the reasons stated above, the services at issue were 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 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that Charalampidis and colleagues performed a review summarizing relevant studies regarding the utilization of intraoperative neurophysiological monitoring technique in spine surgery. The authors concluded, aAlthough there are no prospective studies validating the efficacy of IONM, there is a growing body of evidence supporting its use during spinal surgery. However, the lack of validated protocols to manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines.a This 61-year-old male was being treated for strain of the lumbar region; sacral back pain; lumbar spondylosis; lumbar radiculopathy; pars defect of lumbar spine; chronic low back pain with bilateral sciatica, unspecified back pain laterally; and spondylolisthesis of the lumbar region. The treatment plan included a single level posterior lumbar fusion at L5-S1. Intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery was requested. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support this request as an exception. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for monitored anesthesia care provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. According to the American Society of Anesthesiologists (ASA), monitored anesthesia care is a planned procedure during which the patient undergoes local anesthesia together with sedation and analgesia. When there is documentation in the patients medical record that specific risk factors or significant medical conditions are present, monitored anesthesia care is clinically indicated. Some factors or significant medical conditions may include patients with potential for difficult intubation and/or ventilation with a mask, at risk for airway obstruction, increased risk for complication due to severe co-morbidity, American Society of Anesthesiologists (ASA) class III physical status or greater, history of myocardial infarction, history of stroke, insulin dependent diabetes, poorly controlled disorders, asthma, psychiatric disorders, dysrhythmias, patients with chronic degenerative neurologic diseases which may cause difficulty swallowing or pose a risk for muscle weakness and respiratory failure, morbid obesity or extremes of age such as older than 70 years or younger than 18 years of age. In this case, the patient had no significant past medical history to indicate that monitored anesthesia care was medically necessary. During a screening colonoscopy for a healthy adult, the standard of practice is for the endoscopy nurse, under the guidance and supervision of the gastroenterologist, to monitor vital signs and pulse oximetry and administer sedation/analgesia, with medications such as midazolam and fentanyl. For the reasons provided, the services at issue were 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 66-year-old female enrollee has requested reimbursement for laboratory testing (CPT code 84999) provided on 9/4/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that there is currently insufficient medical evidence to support the effectiveness of Anser ADA compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect (Morita, et al; Roblin, et al). Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels (Yarur, et al). Moreover, controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, the laboratory testing (CPT code 84999) provided on 9/4/17 was not 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 31-year-old female enrollee has requested reimbursement for residential substance abuse treatment services provided from 6/16/14 through 8/16/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that The records indicate that this patients last use of alcohol was 10 days prior to admission and did not require detoxification. She had no post-acute withdrawal symptoms, she was not a danger to herself or others, and had no self-harm urges. She was medically stable as her Crohns disease did not require management in the residential setting. Her psychiatric medications were unchanged during the course of her stay. She presented as motivated and insightful, aware that she needed help maintaining sobriety and having the desire to gain insight. She had two prior periods of prolonged abstinence, demonstrating the ability to remain sober in an unstructured environment. She had prior residential treatment and exposure to AA, thereby having a degree knowledge of relapse prevention and sober supports in the community. Moreover, her environment was supportive. The patient could have adequate and effective treatment on an ambulatory level such as partial hospitalization program (PHP) or intensive outpatient program (IOP), and did not require residential level of care. Thus, the residential substance abuse treatment services provided from 6/16/14 through 8/16/14 were not medically necessary for treatment of this patients substance use disorder. Based on the foregoing discussion, the services at issue were 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 66-year-old male enrollee has requested reimbursement for LINX procedure/device performed on 7/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has history of belching and heartburn. The physician reviewer found For this patient, the services at issue were not superior to the available standard therapy for treatment of his medical condition. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. Per Sheu and colleagues in Curr Opin Gastroenterol, the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined.  Loh and colleagues concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments. Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Moreover, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). The available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial, in this patients case, than standard treatment of surgical fundoplication. As such, per the available literature and relevant clinical guidelines, LINX procedure/device performed on 7/27/16 was not likely to be more effective than other standard therapy for the treatment of this patient. 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this patients case.  Chromosome microarray testing has been accepted as an appropriate first-line genetic testing for patients with autism spectrum disorders.  The testing has the potential to impact treatment, as this may allow the provider to better understand why the patient has certain medical issues. Management also deals with psychological, family, and educational needs, and may vary drastically depending on what is causing a patients issue.  Therefore, comparative genomic hybridization performed on 1/19/15 was likely to have been of greater benefit than 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: Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 1/16/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, the DecisionDx-Melanoma test performed on 1/16/19 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a four-year-old male enrollee has requested reimbursement for comparative genomic hybridization performed on 1/19/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this clinical setting.  The use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders.  Shen and colleagues noted that chromosomal microarray analysis had the highest detection rate among clinically available genetic tests for patients with ASD. Interpretation of microarray data is complicated by the presence of both novel and recurrent copy-number variants of unknown significance.  The authors reported that chromosomal microarray testing should be considered as part of the initial diagnostic evaluation of patients with ASD.  Based on the literature and current standard of practice, comparative genomic hybridization was likely to have been more beneficial than any other available evaluations.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement of collagen crosslinking test (CPT 82523) performed on 9/07/18. 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 Osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. Bone mineral density assessment, via DEXA, is the standard for evaluation and diagnosis of osteoporosis. Since changes in bone mass and density in response to antiresorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. The medical evidence suggests that biochemical markers may assist in making therapeutic decisions. In general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. There is sufficient support for the services at issue in this clinical setting. Therefore, collagen crosslinking test (CPT 82523) performed on 9/07/18 was likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a 13-year-old female enrollee has requested reimbursement for transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Scrambler Therapy has been shown to be beneficial for complex regional pain syndrome. In this patients case, the records document complex regional pain syndrome. She has been treated with physical therapy, epidurals, and other conservative treatment options and pain management techniques, without significant pain relief. Prior treatment with Scrambler Therapy in 2018 was reportedly beneficial. There are clinical trials and journal articles that show statistically significant benefit utilizing these modalities for complex regional pain syndrome. There is sufficient support for the services at issue in this clinical setting. All told, transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


[INSERTA 56-year-old male enrollee has requested reimbursement for service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16. 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 there are medical studies that support the efficacy of the services at issue in this clinical setting. Molecular assays have been developed in an effort to improve decision making for those patients who have been newly diagnosed. These assays have also been utilized for those patients who are already in treatment but may be considering adjuvant therapy or treatment for recurrence. For patients with clinically localized disease, tumor based molecular assays may also be considered. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. These include, but are not limited to, likelihood of death with conservative management, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. There are several test available and recommended by the NCCN guidelines, including OncotypeDx prostate. In this patients case, he meets the NCCN criteria.  In sum, service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16 was likely to have been more effective than the standard treatment options for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for the 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 91-year-old male enrollee has requested reimbursement for services provided from 3/13/18 through 3/16/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute on chronic diastolic heart failure. The physician reviewer found that the records provided for review document that this patient presented with dyspnea on exertion. He was mildly bradycardic, his blood pressure was normal, his respiratory rate was 20, and he was not hypoxic on room air. His anemia and renal function had worsened, with a creatinine almost double his baseline. On 3/15/18, the patient was transfused PRBCs when his hemoglobin dropped below 7. His symptoms appeared to improve with a transfusion of PRBCs and additional diuretics. His renal function returned to baseline with careful diuretic administration. This patient met the criteria for admission and treatment in the telemetry unit given the presence of worsening CHF on imaging, increase of creatinine to twice the level of baseline, and hemoglobin less than 7. All told, the services provided from 3/13/18 through 3/16/18 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.