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

Summary Reviewer 1

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 complex regional pain syndrome is a debilitating chronic pain syndrome that poses incredible challenges to the patient. Clear pathophysiology of complex regional pain syndrome is still being understood, and treatment options are primarily based on clinical experience and individual patients response to therapies, as strong evidence-based treatment options are lacking. A recent review by Shim and colleagues highlighted early use of physical/occupational therapy with neuropathic medications. Neuromodulation is also an option with evidence for appropriate candidates. 

Scrambler Therapy is an electro-analgesia therapy with the intent to re-organize maladaptive signaling pathways that exist in chronic pain. It is used for the treatment of cancer pain, chronic neuropathic pain and refractory pain conditions. A review by Majithia and colleagues concluded that findings from available studies support Scrambler Therapy as a beneficial treatment option for patients with refractory pain syndromes. An observational study by Ricci and colleagues consisting of 219 patients with chronic pain treated with Scrambler Therapy showed a statistically significant impact of Scrambler Therapy. In this case, the patient is experiencing exacerbations of pain from complex regional pain syndrome that has been refractory to other treatments, and she has benefited from Scrambler Therapy in the past. Therefore, 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

The patient is a 17-year-old female with a medical history significant for daily migraine headaches refractory to standard outpatient management, periods of nausea and dizziness, and a diagnosis of postural orthostatic tachycardia syndrome (POTS). The records documented concern for an underlying mitochondrial disorder as the unifying diagnosis for her complex symptomatology. Thus, mitochondrial genome sequencing was ordered and performed. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  Mitochondria are responsible for cellular energy production in nucleated cells. Dysfunction may occur as a result of defects in either mitochondrial DNA or nuclear mitochondrial genes, and resulting disease may present in either adulthood or childhood. Symptoms may affect one organ or may involve multiple systems. While there is no cure for mitochondrial disease at present, genetic diagnosis is essential for guiding supportive care, as well as providing counselling to families and the patient. Next generation sequencing techniques have been invaluable in diagnosing patients with clinical findings suggestive of mitochondrial disease. In this patients case, she has numerous clinical and biochemical abnormalities that have raised the question of mitochondrial disorder. The information provided by next generation sequencing was important for guiding her future care. In sum, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 was likely to have been more effective 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 59-year-old male enrollee has requested reimbursement for the UroLift procedure performed on 4/3/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees elevated prostate specific antigen (PSA) and enlarged prostate with lower urinary tract symptoms. The physician reviewer found that in the peer-reviewed medical literature, Roehrborn and colleagues reported five year data on treatment of BPH with prostatic UroLift resulted in decreased risk of incontinence, impotence, and bleeding. The minimally invasive nature of the UroLift also makes it an acceptable alternative to medications with difficult side effects particularly in younger patients. Further, prostatic UroLift data before April 2017 demonstrated that this surgery did not preclude more invasive treatment if warranted. Given this support, the UroLift procedure performed on 4/3/17 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 15-year-old female diagnosed with major depressive disorder, recurrent, severe, alcohol use disorder, severe, and self-harm. The records dated 2/8/17 reveal that she was admitted to intensive outpatient program (IOP) therapy on 2/9/17. During the course of treatment, the patient has described detachment and possible dissociation and is described herself as a mediator between her parents. On 4/10/17, she indicated in group therapy that she does not express her anger in adaptive ways and in the past drank alcohol as a method of coping. She indicated that she wanted to learn more adaptive strategies. Her parent has requested reimbursement and prospective authorization and coverage for mental health IOP services from 4/10/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary. By 4/10/17, the patient is noted to have a rather sophisticated understanding of her behavior in response to the dysfunction of her family. She appeared to be prepared to continue individual therapy supported by psychotropic medication. In addition to her diagnoses of major depression, and substance abuse, consideration might have been given to reactive attachment disorder with focus on treatments such as acceptance and commitment therapy as well as intensive in-home therapy with multiple systems therapy. These considerations are important because of the patients own experience of having to mediate conflict within the family (Cohen, et al). All told, the records provided for review do not support the medical necessity of the IOP services provided to this patient from 4/10/17 forward.  Based on the foregoing discussion, 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 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.  The physician reviewer found that based on the records provided, the patient presented with newly recognized severe left ventricular dysfunction in the setting of rapid atrial fibrillation and liver enzyme elevation. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. Moreover, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed when continued left ventricular dysfunction is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome (Hohnloser, et al). Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). Given these findings, the Life Vest provided to this patient on 5/23/14 was not 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 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 1

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that patient has an absolute indication for anticoagulation therapy, but he had a major gastrointestinal bleed while on anticoagulation therapy. His provider noted that the patient remains at risk for recurrent gastrointestinal bleeding if he remains on the required lifelong anticoagulation. The Watchman device can obviate the need for long-term anticoagulation in patients at risk for significant bleeding, as is the case with this patient. The Watchman device is both a safe and effective alternative to prevent recurrent stroke in patients with persistent atrial fibrillation who are at high bleeding risk during long-term anticoagulation therapy. Therefore, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 55-year-old male has requested reimbursement for high-intensity focused ultrasound performed on 8/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that high-intensity focused ultrasound has increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low to moderate risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short to intermediate term outcomes for localized prostate cancer. There is a lack of controlled trials available for analysis, and a lack of long-term survival data is available. There are no validated biochemical and surrogate end-point for cure. The National Comprehensive Cancer Network indicates that further study is warranted. The current evidence has not established the superior efficacy of the services at issue. Therefore, high-intensity focused ultrasound performed on 8/14/17 was not likely to have been of greater benefit than other treatment options. 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: Upheld

Summary Reviewer 3

A 41-year-old male enrollee has requested reimbursement for elastase pancreatic fecal and fecal calprotectin laboratory testing performed on 8/03/18. 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 there is sufficient support for the services at issue in this clinical setting. The records document chronic diarrhea. This patients symptoms included abdominal bloating, intermittent watery diarrhea and rectal itching. The documentation noted that the patient tested negative for celiac disease in the past. Expert guidelines for the evaluation of chronic diarrhea have recommended fecal calprotectin testing in the evaluation of diarrhea, as a surrogate for fecal leukocyte testing. This testing can identify whether an inflammatory cause for diarrhea is present. Thus, fecal calprotectin laboratory testing performed on 8/03/18 was likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 57-year-old male with a history of AL amyloidosis with cardiac involvement. Computed tomography (CT) imaging of the pelvis with contrast on 12/21/16 for a history of amyloid light chain amyloidosis revealed stable small pericardial effusion and bilateral renal cysts, unchanged from 5/27/16. The provider reports the patient has been treated with Cytoxan, dexamethasone, Velcade, and Kyprolis. The providers treatment plan is to start Darzalex if these medications are not effective. The patient has requested authorization and coverage for daratumumab (Darzalex). The Health Insurer has denied this request indicating that the requested medication is considered investigational. As reported in the peer-reviewed medical literature, Darzalex was tested in previously treated patients with systemic amyloidosis in two phase II studies (Roussel, et al; Sanchorawala, et al). In these studies, hematologic response rates were approximately 60%, with positive organ responses, and reductions in serum free light chain levels. Given this support, the requested Darzalex 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 68-year old male with a history of diabetes, hypertension and hyperlipidemia. 
The patient has requested reimbursement for hospital services provided from 11/13/21 
through 11/15/21. The physician reviewer found that based on the records, this patient had 
significant cardiac risk. The documentation noted recently diagnosed rapid atrial fibrillation 
with persistent symptoms despite initiation on rate control medication (metoprolol) and 
anticoagulation (Xarelto) as an outpatient. Moreover, unexplained left ventricular dysfunction 
is noted. His troponin was elevated, suggesting possible non ST segment elevation myocardial 
infarction. The patients heart rate has not adequately controlled on medical therapy and 
congestion had developed on chest x-ray despite outpatient therapy. In this clinical setting, 
inpatient admission is medically indicated to establish better rate control and to evaluate for 
acute coronary ischemia. Current guidelines support inpatient admission in this setting. 
Therefore, hospital services provided from 11/13/21 through 11/15/21 were medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 58-year-old female who has a history of opiate use disorder, alcohol, benzodiazepine, amphetamine and cannabis use disorders and past psychiatric history of bipolar disorder  and depression. She presented to an inpatient rehabilitation facility on 8/7/17. She had been using opiates since age 43 for back pain. The patient has requested reimbursement for residential treatment for 8/21/17 through 9/12/17. The Health Insurer denied this request and reported that the services at issue were not medically necessary. This denial is the subject of this appeal and determination. The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. A notation on 8/20/17 indicated that the patients mood and affect were improved. By 8/21/17, the clinical notes show the patient was independently engaging in everyday activities. The patient indicated an ability to function and receive services as an outpatient. Progress note on 8/22/17 reported that the patient attended a yoga class which is a testament to her physical health. She also attended a family barbeque, watched movies and attended beach meetings. The record reported that the patient was engaging with peers and counselors. There were no signs or symptoms of an acute withdrawal or psychiatric symptoms, such as suicidal or homicidal ideations or psychosis. By 8/21/17, the patients symptoms did not necessitate inpatient residential treatment. Such services rendered to the patient for the reimbursement period specified could have been achieved at a lower level of care. Therefore, residential treatment services provided from 8/21/17 through 9/12/17 were not medically necessary. Therefore, 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: Overturned

Summary Reviewer 3

A 44-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/26/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that there is sufficient support for digital breast tomosynthesis in the evaluation of this patient. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. Based upon the information set forth above, the service at issue was likely to have been 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 28-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation and autologous cultured chondrocytes implant for left knee. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees left knee pain.  The physician reviewer found that treatment of osteochondral defects with autologous chondrocyte implantation has been proposed for treatment of this patients cartilage defects in the knee. The patients provider has submitted additional information in support of the patients request for authorization for the procedure. Based upon review of the additional information, the requested procedure is medically reasonable and appropriate in this case. While the evidence regarding autologous chondrocyte is mixed, as noted by the treating provider there is documentation of positive outcomes cited in literature. As such, there is sufficient evidence in the available data to support the efficacy of autologous chondrocyte implantation and autologous cultured chondrocytes implant in this clinical setting. Therefore, the requested procedure is medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not known how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not clear if DecisionDx-Melanoma testing can be used to make clinical decisions about treatment. Therefore, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request 
indicating that the requested services are considered investigational for evaluation of the insureds 
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that 
this patient reportedly presented to his provider in November 2022 with complaints of viral 
symptoms including myalgias, congestion, and lethargy. The provider noted that the patients 
symptoms were concerning for an acute viral syndrome. Considering the time of the year and the 
patients recent exposure to ill contacts the was a reasonable concern for a viral etiology. As such, 
testing for multiple viral etiologies is the standard of care for this clinical scenario. In addition, co-
infections are common and could also be diagnosed with this method. The patient underwent 
testing with BioFire 2.1 Respiratory Panel, which is a common testing modality. Leber and 
colleagues  noted  that  the  BioFire  FilmArray  Respiratory  Panel  2  (RP2)  is  a  multiplex in 
vitro diagnostic  test  for  the  simultaneous  and  rapid  detection  of  22  pathogens  from  a 
nasopharyngeal swab sample. The authors reported that the RP2 testing system was shown to be 
reliable, with very few failures (99.3% success on the initial test attempt), and rapid, with results 
available in approximately 45 minutes, which is shorter than that of the FilmArray RP. Given this 
support, the Coronavirus COVID-19 (SARS-CoV-2) respiratory panel performed on 11/8/22 was 
likely to be more beneficial for evaluation of the patients medical condition than any available 
standard therapy.