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

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for Aimovig. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with chronic daily migraine. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has taken several migraine prophylactic medications without success.  However, the Health Insurer has requested that the patient fail two medications (for at least two months each) amongst a list of several options.  With regards to these alternatives, the documentation provided shows the patient has failed onabotulinumtoxinA. While there is mention of topiramate in the submitted documentation, there is insufficient information regarding the parameters of this failure, including, but not limited to, length of therapy prior to failure. There is a lack of evidence indicating superiority of Aimovig compared to the alternatives offered by the Health Insurer. All told, Aimovig is not medically necessary for the treatment of this patient. Therefore, the requested medication is 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 60-year-old female enrollee has requested authorization and coverage for Harvoni for 12 weeks. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found the requested medication quantity is not medically necessary for the treatment of this patient.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  However, in this patients case, the Health Insurer has offered coverage for Harvoni for eight weeks.  Per the medical evidence, since the patients viral load is less than 6,000,000 IU/mL, Harvoni for eight weeks is medically appropriate.  Therefore, the requested medication quantity is 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 

The parent of a three-year-old female enrollee has requested reimbursement for acute care hospital admission from 7/01/18 through 7/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who experienced bleeding following tonsillectomy.  The physician reviewer found that an adenotonsillectomy is a common surgical procedure in children and is considered to be painful, particularly in the early postoperative period. Up to a week postoperative, children continue to complain of significant discomfort. Patients frequently seek out medical attention, with the majority of patients returning during the first postoperative week for evaluation of bleeding, pain, and dehydration. This patient underwent tonsillectomy, experiencing one episode of post-tonsillectomy bleeding with clot formation. She was referred to the emergency department by the surgeon, and was hemodynamically stable upon presentation. She was admitted, with no further episodes of bleeding. While it was reasonable to monitor her in the hospital post-hemorrhage to establish ability to tolerate food and fluids by mouth, to determine adequacy of pain management, and to ensure no further bleeding, she was overall stable and did not require acute inpatient management. She could have been safely managed at a lower level of care, such as observation. Thus, acute care hospital admission from 7/01/18 through 7/02/18 was not medically necessary for the treatment of this patient. Therefore, 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 1

A 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/14/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts.The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis, to the usual two dimensional protocol was likely to be more effective than had the patients examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service 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 62-year-old female enrollee has requested authorization and coverage for Lucentis (ranibizumab intravitreal solution pref syr 0.5 mg/0.05 ml). 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 the submitted documentation supports the medical necessity of the requested medication. Gerding and colleagues reviewed outcomes studies on the use of ranibizumab and recommended early treatment of macular edema associated with retinal vein occlusion. Other studies have demonstrated that this medication is safe and effective for decreasing macular edema and improving visual acuity compared to the previous standard of care treatment, focal laser treatment. Intravitreal anti-VEGF drugs, such as ranibizumab, are the standard of care treatment for this patients disease. Based on the medical records, the patient has macular edema secondary to central retinal vein occlusion. As the patient has central retinal vein occlusion with macular edema, ranibizumab is an appropriate, clinically effective treatment and is medically necessary. Therefore, Lucentis (ranibizumab intravitreal solution prefilled syringe 0.5 mg/0.05 ml) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator performed on 7/25/18, 8/25/18 and 9/25/18. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the device at issue in this clinical setting. The high risk of sudden cardiac death in patients with severe left ventricular dysfunction has led to the recommendation of implantable cardioverter defibrillators in this group of patients. Current data from multiple trials and registries have advocated the use of a wearable cardioverter defibrillator after an initial diagnosis of severe left ventricular dysfunction (ejection fraction of 35% or less). This patients ejection fraction was 20%. Given the absence of significant coronary obstructive disease at catheterization, a diagnosis of non-ischemic cardiomyopathy was made. Current guidelines recommend against placement of an implantable cardioverter defibrillator within 40 days of an acute myocardial infarction, or within 90 days of an initial diagnosis of congestive heart failure in the presence of a severely depressed ejection fraction. Therefore, a wearable cardioverter defibrillator was appropriate for a period of 90 days (dates of service 7/25/18, 8/25/18 and 9/25/18), given the patients severely depressed ejection fraction. In sum, the wearable cardioverter defibrillator provided on 7/25/18, 8/25/18 and 9/25/18 was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this patientas case. She has failed continuous positive airway pressure therapy and is not an optimal candidate for oral appliance therapy due to the severity of her obstructive sleep apnea. The alternative, no treatment, may lead to potential harms, such as increased medical comorbidities, including hypertension, diabetes, congestive heart failure, myocardial infarction, and stroke. There is sufficient evidence in the peer-reviewed literature to support the safety, efficacy, and long-term outcome in the treatment of obstructive sleep apnea with hypoglossal nerve stimulation or Inspire airway stimulation. Multiple published studies show clinically significant decreases in observed mean apnea-hypopnea index and Epworth Sleepiness Scale scores.  The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. 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 that the requested surgery is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature supporting anterior vertebral body tethering (VBT), which is a fusionless treatment option for management of idiopathic adolescent scoliosis. The study by Samdani and colleagues is a retrospective chart review which evaluated the clinical and radiographic outcomes of anterior VBT at one-year follow-up. The authors concluded that the results indicate that anterior VBT is a safe and potentially effective treatment option for skeletally immature patients with idiopathic scoliosis. These patients experienced an improvement of their scoliosis with minimal major complications. Given the above, surgery for scoliosis is likely to be more beneficial for treatment of thepatients medical condition than any available standard therapy. 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: Medical Necessity
Decision: Overturned

Summary  
The patient is a 69-year-old male who presented to his provider on 8/5/21. The patient has 
requested reimbursement for insertion of multi-component, inflatable penile prosthesis, including 
placement of pump cylinders, and reservoir on 3/22/23. The Health Insurer has denied this request 
and reported that the service at issue was not medically necessary for the treatment of this patient 
and is not reconstructive in nature. This denial is the subject of this appeal and determination. The 
physician reviewer found that he submitted documentation supports the medical necessity of the 
service at issue. The American Urological Association (AUA) guidelines for the treatment of 
erectile dysfunction support the placement of a penile prosthesis for the treatment of organic 
erectile dysfunction. In this case, given that the patient has tried and failed first and second line 
therapies for erectile dysfunction, the service at issue was medically indicated. Therefore, insertion 
of multi-component, inflatable penile prosthesis, including placement of pump cylinders, and 
reservoir on 3/22/23 was medically necessary for the treatment of this patient. The California 
reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as 
surgery performed to correct or repair abnormal structures of the body caused by congenital 
defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the 
following: (1) to improve function; (2) to create a normal appearance, to the extent possible. In 
this case, the condition was caused by disease, prostate cancer, and its treatment, which disrupted 
the nerves responsible for erectile function, resulting in organic erectile dysfunction. The abnormal 
nerve function was due to disease, prostate cancer, and its treatment. The service at issue was 
meant to improve function by improving organic erectile dysfunction and restored erectile function 
for the patient. Therefore, insertion of multi-component, inflatable penile prosthesis, including 
placement of pump cylinders, and reservoir on 3/22/23 was reconstructive in nature for treatment 
of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a 10-year-old male enrollee has requested reimbursement for the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that regardless of the etiology for transverse myelitis, flaccid myelitis and other infectious or post-infectious etiologies for spinal cord injury (SCI), the impact on activities of daily living are profound. These include, but are not limited to, loss of muscle mass, decreased bone density in affected limbs, abnormal blood flow and injuries incurred because of weakness and abnormal sensory input. While there is no currently available therapy to repair or replace affected spinal cord neurons, functional electrical stimulation provides trophic and functional support to muscles and limbs affected by SCI. Furthermore, this type of stimulation and therapy may preserve cortical representations of complex motor activity programs. While functional electrical stimulation cannot replace irrevocably injured or apoptotic spinal cord neurons, it can restore function below the level of injury. Hence, this represents best medical practice to restore/maintain this member's level of neurologic function. Therefore, the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 63-year-old male who was diagnosed in 2015 with mild obstructive sleep apnea with an apnea-hypopnea index of 8 per hour. The patient failed oral appliance treatment. He was recently diagnosed with lung sarcoidosis. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. This patient was diagnosed with obstructive sleep apnea by a home sleep study in 2015. This type of testing can underestimate the severity of the patients disease. He failed oral appliance. The patient is symptomatic and has lung sarcoidosis, which may affect the accuracy of a new home sleep study. Per the records, CPT code 95811 is medically indicated to diagnose and treat this patient appropriately. Therefore, CPT 95811, split night sleep study, is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 31-year-old male enrollee has requested reimbursement for physical therapy provided from 9/29/17 through 2/23/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees back pain. The physician reviewer found that soft-tissue and palliative interventions, e.g., self-massage using foam rollers or massage balls, and topical treatments such as ice or heat, during the time period under review.  Although the patient had ongoing symptoms, there was no expectation of a marginally significant difference in clinical course or outcomes with the therapies in question over an independent program. Thus, physical therapy provided from 9/29/17 through 2/23/18 were not medically necessary for the treatment of this patient. Therefore, 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 1

A 46-year-old female enrollee has requested reimbursement for CPT code 84999 performed on 1/12/17. 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 the prognosis for cutaneous melanoma has classically been determined by applying the staging spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics.  By Balch staging, this melanoma would be classified as a T1a (stage 1A), with an expected ten-year survival of at least 88%.  DecisionDx is a study of 31 genes in an individuals melanoma cells. It then classifies that melanoma as either Class 1 (with a 90-92% disease-free survival at five years), or Class 2 (with a 48-77% five-year disease-free survival). Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx classification, in patients who had undergone sentinel node biopsy. However, it is not clear how the five-year DecisionDx data compares to the ten-year Balch data, and, most importantly, whether it can be used additionally to make clinical decisions. This is especially true in this patient with an excellent prognosis. At this time, the superior effectiveness of CPT code 84999 performed on 1/12/17 has not been established. 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: Upheld

Summary Reviewer 2


A 68-year-old male enrollee has requested reimbursement for proton beam radiation therapy. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were not likely to be more effective for this patient than other available options. Protons have been used to treat prostate cancer for last several years. There is some support in the literature for the safety and efficacy of proton beam radiation therapy for prostate cancer. However, there is a lack of randomized trial suggesting superior clinical outcome of proton beam for prostate cancer over intensity-modulated radiation therapy (IMRT). For the reasons provided, the services at issue have not been established as likely to be more beneficial than standard medical therapy. 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 2

A 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for Actemra provided from 7/14/15 through 12/15/15 and ongoing. The Health Insurer has denied this request indicating that the medication at issue was and is investigational for the treatment of the enrollees medical condition.  The physician reviewer found that at this time there is an unmet need in the treatment of AMR for renal transplant recipients. In this case, the patient has received IVIG, Rituximab and pulse steroids for the treatment of his chronic active AMR which are acceptable treatments. However, the patient did not have plasmapheresis in an attempt to remove the DSAs, the latter probably associated with the AMR. Plasmapheresis is a standard treatment which is performed in most patients with AMR either alone or in conjunction with the therapies that this patient received. Also, there are several reports in the peer-reviewed literature of other potential therapies such as bortezomib and eculizumab in the treatment of patients with AMR. This patient has not been tried on these therapies. Moreover, there is a lack of studies on the use of tocilizumab in the treatment of AMR, except as an investigational drug. This is not a standard therapy for AMR and has not been recommended by the American Society of Transplantation or received U.S. Food and Drug Administration (FDA) approval for this indication. More randomized controlled trials are required comparing tocilizumab to the currently available anti-AMR therapies. In addition, the patients renal function has been stable and the usage of tocilizumab has not made it better thus far. For the reasons provided, the medication at issue was not and 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 medication at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3
A 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx Melanoma Gene assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the treatment of the patients melanoma. Thus its usage is not expected to impact the treatment or outcome of the patients melanoma. For the reasons provided, the testing at issue 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.