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

Summary Reviewer  
 
The patient is a 20-year-old female who sustained severe injuries with a Glasgow Coma Score 
(GCS) of 6 from a motor vehicle versus cyclist accident on 5/2/23. The provider noted that the 
patients pulse was 100 beats per minute on the date of transport. The patient has requested 
reimbursement for the air and ground ambulance services provided on 6/23/22. The physician 
reviewer found that the records provided for review document that this patient sustained TBI, 
SDH, SAH, complex pelvic fractures, and an open tibia fracture in a motor vehicle versus bicycle 
accident on 6/23/22. Based on review of the level of injuries sustained, including internal 
hemorrhage and brain injury, this patient would have warranted air transport in order to 
expedite  the  transfer.  The  provider  recommended  transfer  for  the  patient  to  undergo 
neurological rehabilitation from an intensive multidisciplinary approach to maximize functional 
independence. The records document that the patient had a pulse of 100 beats per minute on 
the day of transport, which could have represented ongoing or recurrent internal hemorrhage. 
Given the extent and severity of the patients injuries, transport by any other means such as 
ground ambulance for the entire transfer would have placed the patients long-term health at 
risk. Moreover, the use of air and ground transport for this patient was consistent with the 
recommendations from the Centers for Disease Control and Prevention (CDC). Therefore, the air 
and ground ambulance services provided on 6/23/22 were medically necessary for treatment of 
this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 may add a bit more 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 risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year data of Balch. Most importantly, it is unclear whether DecisionDx-Melanoma data can be used to make clinical decisions. Therefore, gene expression profiling performed on 5/14/17 was not 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 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 1


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 10/21/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for treatment of the enrollees risk for breast cancer.  The physician reviewer found in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 10/21/15 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for gene tests performed on 6/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees non-small cell lung cancer. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer.  Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, gene tests performed on 6/09/16 were likely to be more beneficial than other methods of evaluating this patient. Based upon the information set forth above, the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 53-year-old male enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees major depressive disorder. The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. The procedure is well tolerated with fewer barriers and side effects than electroconvulsive therapy. TMS is U.S. Food and Drug Administration (FDA) approved and supported by the American Psychiatric Association (APA) for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Further, the APA made no mention of pre-requisite psychotherapy. Thus, the standard of care does not require a certain course of psychotherapy prior to TMS. In this case, the patient remains symptomatic despite first-line medications and psychotherapy. Considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice that is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested TMS is medically necessary for treatment of the patients major depressive disorder. Therefore, the requested service is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 41-year-old male with a diagnosis of chronic migraine. He has been on multiple antidepressant medications. The patient has also been treated with amlodipine and topiramate. A headache diary confirms the presence of chronic daily headache. The patient has requested reimbursement for Botox injections provided on 10/16/17 and 1/08/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.  The medical evidence supports the services at issue in this clinical setting. This patients records support the diagnosis of chronic migraine. He has already been on several preventive agents. Botox injections was appropriate in this patients case. Thus, Botox injections provided on 10/16/17 and 1/08/18 were likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the services at issue were 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 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. 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 human epididymis protein 4 (HE4) is a blood tumor marker that is often used in the management of ovarian carcinoma. There has been interest in applying HE4 in the management of endometrial cancer, particularly the endometrioid variant, as seen in this patients case. In 2019, Li and colleagues demonstrated that HE4 is superior to CA-125 in the detection of endometrial cancer. In 2015, Li and colleagues demonstrated that the level of HE4 correlates with prognosis. Plotti and colleagues reviewed 49 articles relevant to this issue, and the authors reported that HE4 was promising in endometrioid endometrial cancer. Therefore, HE4 testing performed on 9/20/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram (breast tomosynthesis) provided on 1/9/17. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer.  The physician reviewer found there is a lack of peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature as superior to currently available standard medical therapies. Accordingly, the 3D mammogram (breast tomosynthesis) provided on 1/9/17 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 service 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: Overturned

Summary Reviewer 

The patient is a 54-year-old male who was transported via air ambulance on 10/11/20. The patient has requested reimbursement for air ambulance transportation provided on 10/11/20. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. In order to be medically necessary, specific criteria must be met. These criteria include the following: the individualas condition must be such any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. This patient was struck by the door of his own vehicle as it rolled from a neutral position, dragging him approximately 25 feet before the rear of the vehicle struck a tree. The patient sustained multiple bilateral rib fractures with bilateral pneumothoraces and a liver laceration, from which he could have exsanguinated. Based on the mechanism of injury, and the time needed for ground transport, air ambulance services were medically necessary in this case. Therefore, air ambulance transportation provided on 10/11/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


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 in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 3/11/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 64-year-old female enrollee has requested placement of permanent sacral nerve stimulator performed on 12/09/14.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees fecal incontinence. The physician reviewer found in this patients case, the submitted records fail to establish the superior effectiveness of the services at issue.  The clinical records did not provide details regarding what treatments had been tried and failed for her condition.  Although the use of sacral nerve stimulation appears to hold promise in many patients with fecal incontinence, the records were insufficient to support the services at issue in this case.  Thus, the permanent sacral nerve stimulator provided on 12/09/14 was not likely to be of greater benefit than other available 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 20-year-old male enrollee has requested authorization and coverage for chondrocyte implantation with Denovo. 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 per Vasiliadis and Wasiak, treatments for managing articular cartilage defects of the knee, including drilling and abrasion arthroplasty, are not always effective.  An alternative is autologous chondrocyte implantation.  The authors reviewed 431 cases in 6 trials.  The authors noted that additional good quality randomized controlled trials with long-term functional outcomes are required to draw conclusions on the use of autologous chondrocyte implantation for treating full thickness articular cartilage defects in the knee.  Farr and colleagues noted the need for prospective, randomized controlled studies to refine the indications and contraindications for the requested services.  Thus, chondrocyte implantation with Denovo is not likely to be of greater benefit than 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: Upheld

Summary Reviewer 3 
 
A 24-year-old male enrollee has requested reimbursement for an implantable interstitial 
glucose sensor on 1/7/22. The Health Insurer has denied this request and reported that the 
device at issue was investigational for the treatment of the enrollees type 1 diabetes. The 
physician reviewer found that blood glucose monitoring is essential to diabetes management. 
Options for blood glucose monitoring include self-monitoring of blood sugars (SMBG) with 
fingersticks and use of a glucometer or via use of a rtCGM or isCGM. As compared with SMBG, 
rtCGM and isCGM technology have been shown to improve glycemic control in patients with 
type 1 and type 2 diabetes mellitus. The American Diabetes Association Professional Practice 
Committee notes, Real-time continuous glucose monitoring or intermittently scanned 
continuous glucose monitoring should be offered for diabetes management in adults with 
diabetes on multiple daily injections or continuous subcutaneous insulin infusion who are 
capable of using devices safely (either by themselves or with a caregiver). There are several 
available CGMS including the Eversense CGMS. Historical data from the system can be used 
nonadjunctively to replace SMBG for making diabetes treatment decisions, although it requires 
two fingersticks daily with SMBG for calibration. There is a lack of guidance advocating use of 
one type of CGM over another and mixed data on the benefits of one CGM over another. Jafri 
and colleagues evaluated 23 adults with type 1 diabetes over six weeks comparing the 
Eversense, DexCom G5, and FreeStyle Libre Pro. The authors found that the Eversense achieved 
the lowest overall mean absolute relative difference (MARD) in glucose values. However, in an 
evaluation of 11 patients with type 1 diabetes who initially were at home and on day three, 
moved to a monitored setting for four days, Boscari and colleagues reported the DexCom G5 
was more accurate in monitoring blood sugars than the Eversense. The authors noted that  during the period of intense monitoring, the DexCom G5 showed overall smaller MARD than 
the Eversense, concluding that the DexCom 5 was more accurate than the Eversense for 
glucose monitoring. While CGM devices are widely popular as a means of monitoring blood 
sugars for the management of diabetes and are beneficial in improving glycemic control, there 
is a lack of data in current medical literature evaluating all types of CGMs available and small 
trials have shown contradictory results. In this clinical setting, an implantable interstitial glucose 
sensor was not likely to have been more beneficial for treatment of the patients medical 
condition than any available standard therapy such as with rtCGM and/or isCGM. Therefore, an 
implantable interstitial glucose sensor on 1/7/22 was not likely to have been more beneficial 
for treatment of the patients condition than any available standard therapy
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 63-year-old male with an elevated prostate-specific antigen (PSA) of 10. A computed tomography (CT) scan of the abdomen and pelvis dated 8/21/17 showed a large prostate, thick bladder with calculi, intermittent hematuria, large calcifications, and left low pole bladder stone of 1.5 cm. On 8/24/17, a transrectal ultrasound and magnetic resonance imaging (MRI) of the prostate, guided needle placement, prostate biopsy, and a cystolitholapaxy revealed the prostate was enlarged with a volume of 45 mL, biopsy was negative, and the bladder was moderate to severely trabeculated with multiple saccules and small diverticula with a stone of 1.5 x 2.5 cm. In a progress note dated 11/27/17, the provider reported that the patients PSA was above 10 and recommended the Uroflow procedure. The patient has requested authorization and coverage for a prostatic urethral lift implant. The Health Insurer has denied this request indicating that the requested surgical procedure is considered investigational. The UroLift procedure has been shown to be successful in treating symptomatic benign prostatic hyperplasia (BPH) without adversely affecting a patients quality of life. Based on the current literature, the prostatic urethral lift can be considered as an option for symptomatic BPH patients with small or medium size prostates defined as 80 mL or less without median lobe enlargement, who failed or are intolerant to medical therapy and wish to preserve their sexual function. However, this patient was treated for irritative urinary symptoms related to bladder stone. His symptoms have markedly improved after removal of the bladder stone and are controlled while on medication. Therefore, the requested prostatic urethral lift implant is not 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 61-year-old female. In a letter dated 9/19/22, the provider reported that the patient 
has post-menopausal osteoporosis and scoliosis, with a T-score of -3.0 at the hip. The patient has 
requested authorization and coverage for teriparatide (FORTEO) injection pen, inject 20 mcg 
under skin. The Health Plan has denied this request and reported 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. Khosla and Hofbauer state, Osteoporosis is an enormous 
and growing public health problem. Once considered an inevitable consequence of ageing, it is 
now  eminently  preventable  and  treatable.    While  anti-resorptive  drugs,  especially 
bisphosphonates, have traditionally been considered the treatment of choice, Li and colleagues 
report that pro-formative anabolic drugs, such as Forteo, have attracted wide attention in recent 
years. The authors further note that randomized controlled trials show a higher efficacy in the 
reduced incidence of vertebral and non-vertebral fractures with the use of teriparatide (brand name 
Forteo)  than  bisphosphonates  such  as  risedronate.  Forteo  influences  both  cartilaginous  and 
mineralized callus formation in the fracture healing process, in contrast to other agents such as 
Prolia and Tymlos, which do not increase rates of bony fusion. Therefore, teriparatide (FORTEO) 
injection pen, inject 20 mcg under skin, is medically necessary for the treatment of this patient.