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

Summary Reviewer 


A 38-year-old female enrollee has requested reimbursement for substance use partial hospitalization program services provided from 8/22/16 through 8/26/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a nationally accepted tool for determining the appropriate level of care. Based on LOCUS, partial hospitalization program services were not medically indicated.  This patient presented with a low risk of harm.  She had no current suicidal or homicidal ideation. She had passive suicidal thoughts, but no plan.  In terms of functional status, the records documented moderate impairment. Due to her substance use, she was not fulfilling her responsibilities. She was having interpersonal conflicts with her husband over her substance use. The records documented the significant comorbidity of her ongoing substance use despite negative consequences. The documentation noted a moderately stressful recovery environment. There were conflicts in the patients relationship with her husband over her current substance use. The patients husband takes Tramadol, which is a significant trigger for the patient as she has recently abused this drug. However, she has a supportive environment. Her husband was described as supportive. She has a good relationship with her children and her stepmother. The patient had a significant response to past treatment. She was sober for 15 years, which is a substantial period of time. The records documented that the patient accepted her illness and was engaged in her recovery. She attended groups and psychotherapy. Based on these factors, the patient met the criteria for an intensive outpatient program during the dates of service in dispute. Thus, substance use partial hospitalization program services provided from 8/22/16 through 8/26/16 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 55-year-old transgender female enrollee has requested authorization and coverage for facial feminization surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that gender reassignment traditionally includes psychotherapy, hormonal therapy, and surgery.  This has been demonstrated as the most effective treatment for patients with gender dysphoria. The World Professional Association for Transgender Health has published guidelines and standards of care, including what they consider eligibility criteria for surgery. In this patients case, the records do not document a comprehensive psychiatric evaluation. Further, in studying the quality of life of transgender male to female individuals, one large scale study by Ainsworth and Spiegel suggested that facial feminization did not have a statistically significant outcome in mental health features in these patients. Therefore, the requested facial feminization surgery is not medically necessary for the treatment of this patient. Therefore, the requested services are 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 47-year-old female enrollee has requested authorization and coverage for a positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees pulmonary blastoma. The physician reviewer found that the use of PET/CT for surveillance in non small cell lung cancer is not supported by the National Comprehensive Cancer Network (NCCN) guidelines absent any clinical evidence of tumor recurrence or imaging finding on conventional studies suspicious for tumor. In this case, the patients most recent PET/CT in April 2016 was negative and a follow-up CT of the chest showed no sign of tumor recurrence. Together with negative serum tumor markers, the requested PET/CT is not medically necessary per NCCN guidelines which state that PET/CT is not routinely indicated for surveillance after definitive therapy. Thus, absent biochemical or conventional imaging findings suggestive of tumor recurrence, the requested PET/CT scan is not medically necessary for evaluation of this patients pulmonary blastoma. Based on the foregoing discussion, the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 44-year-old female enrollee has requested has requested reimbursement for magnetic resonance imaging (MRI) (CPT code 73221) performed on 5/16/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees bilateral shoulder pain. The physician reviewer found the submitted documentation fails to establish the medical necessity of the diagnostic procedure at issue. The clinical documentation submitted for review does not demonstrate that the patient was treated with a trial of conservative therapy such as anti-inflammatory medications, rest, and physical therapy prior to the MRI. In sum, given the lack of support demonstrating the patient underwent a trial of conservative therapy, the MRI (CPT code 73221) performed on 5/16/16 was not medically necessary for evaluation of the patients medical condition.  Therefore, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a seven-year-old female with a history of spinal muscular atrophy (SMA). The 
patient has been diagnosed with decreased functional mobility and has been limited in all areas of 
gross motor development. The patients provider has recommended a wheelchair power seat 
elevation system. The Health Insurer has denied the services at issue as not medically necessary 
for treatment of the patients medical condition. This denial is the subject of this appeal and 
determination. The physician reviewer found that the mobility methods of pediatric patients with 
neuromuscular disorders and impaired mobility include manual and power wheelchairs depending 
on the patients ability to propel themselves and the risk of complications from their underlying 
neurological condition. Power wheelchairs provide a means for pediatric patients with motor 
impairment to achieve age-appropriate self-generated mobility that would not be possible without 
assistance. Developmental benefits, including social, language, and cognitive skill development, 
may be observed in young patients with motor disability who use power wheelchairs. This patient 
requires seat elevation to perform daily activities at school and at home. The wheelchair power 
seat elevation system would provide independence, safety, and efficiency for the patient in 
everyday settings and activities. Additionally, the patients current wheelchair does not provide 
proper femur, pelvic, or lumbar support. The patient demonstrates significant postural deviations 
due to spinal weakness and neuromuscular scoliosis. The power chair elevation system will 
provide appropriate positioning for the patient to help reduce musculoskeletal complications such 
as worsening scoliosis, contractures, pain, and hip deformities. For these reasons, the requested 
wheelchair power seat elevation system is medically necessary for treatment of the patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement for Botox injections provided on 12/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees low back pain and spasms. The physician reviewer found that low back pain is a major cause of disability and can result in substantial morbidity. Botulinum toxin has been used successfully to alleviate pain for a number of conditions caused by muscle contractions or spasms. The medical evidence supports the use of Botox for low back pain and spasms. The study of Jazayeri and colleagues included 50 patients treated for four weeks, with 76% reporting relief. The authors found a low incidence of side effects and concluded that Botox is an effective treatment. This patient had evidence of myofascial pain and spasms with no evidence of radiculopathy or myelopathy. There was sufficient support for the requested services in this clinical setting. Therefore, Botox injections provided on 12/13/17 was likely to have been of greater benefit than other available treatment modalities. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 62-year-old male enrollee has requested authorization and coverage for sodium fluoride (NaF) 18 positron emission tomography (PET) with computerized tomography (CT), whole body scan. The Health Insurer has denied this request indicating that the requested services not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found that there is support in the medical literature for the requested PET/CT scan in this clinical setting. The documentation indicates that this patient is highly at risk for bone metastasis and his rising PSA is concerning for additional skeletal metastases besides the treated T-12 lesion.  It has been well documented in the medical literature that NaF 18 is far more sensitive than technetium 99M bone scan agents in the detection of metastatic disease to bone in patients with prostate cancer. This patient had a previous NaF 18 PET/CT scan that located his metastatic lesion that was not appreciated on the technetium scan earlier.  Thus, the PET/CT using the more sensitive compound will represent the baseline study with which to compare for progressive metastatic bone disease. All told, NaF 18 PET/CT, whole body scan is medically necessary for the evaluation of this patients medical condition. Therefore, for these reasons, the requested services are medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer.The physician reviewer found that based on the submitted documentation, the requested proton beam therapy is not likely to be more beneficial photon-based intensity modulated radiation therapy for the treatment of the above patients tonsillar cancer. Compared to standard radiotherapy with photon intensity modulated radiation therapy, the benefit of proton beam therapy is that radiation dose is deposited more precisely on its target. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Comparing dosimetric parameters, proton beam therapy will also appear superior than photon-based intensity modulated radiation therapy. However, this dosimetric benefit does not always translate into an actual clinical benefit to the patient. In this patients case, a comparison chart was submitted for proton beam therapy versus intensity modulated radiation therapy, and this showed decreased doses to the spinal cord, brainstem, lips, contralateral parotid gland, and esophagus with proton beam therapy. However, the doses listed for the intensity modulated radiation therapy plan were already under normal tissue tolerance. Thus, the dosimetric improvement with proton beam therapy is not likely to be clinically significant. In sum, the requested proton beam therapy (77499) is not likely to be more effective than other available 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating hepatitis C, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The peer-reviewed literature does not support denying treatment for HCV because the patient does not have an advanced stage disease. Moreover, the AASLD and IDSA recommendations for treating HCV recommend a daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for treatment-naive patients with HCV genotype 1 infection. Therefore, the request for Harvoni is medically necessary for treatment of the patients HCV. For the reasons provided, the requested medication 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 45-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma. The physician reviewer found that bronchial thermoplasty is not generally accepted as standard of care for treatment of asthma. This procedure continues to be experimental or investigational. Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. In a publication by Thompson and colleagues, there was no difference in lung function indices (forced expiratory volume in 1 second) between those patients in the bronchial thermoplasty group and the control group who had visits or admissions into the emergency room. While the provider stated that the patient has had progressive decrease in his quality of life, there is a lack of clinical support to indicate that bronchial thermoplasty would improve the long-term functional outcome of the patients medical condition. For these reasons, the requested procedure is not likely to be superior to standard treatments available for treatment of this patients medical condition. 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: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 54-year-old female enrollee has requested reimbursement for advanced lipoprotein testing 
performed on 4/15/22. 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 in this case, the patient has increased coronary risk.  The American College 
of Cardiology (ACC) and American Heart Association (AHA) guidelines for the management of 
cardiac risk and dyslipidemia do not recommend routine performance of specialized tests in the 
context of assessing coronary risk including coronary calcium quantification, coronary computed 
tomography (CT) scanning, advanced lipoprotein analysis, genetic testing, and homocysteine. 
Treatment changes or additions based on the results of screening with these specialized tests 
have not been shown to improve cardiac outcomes over those achievable by treatment based 
on standard risk factor profiling and basic lipid analysis. While results from some of these 
specialized tests may be abnormal and considered independent risk markers for coronary 
disease, there is a lack of data in controlled trials demonstrating outcome benefits from treating 
routinely obtained abnormal results. Therefore, advanced lipoprotein testing performed on 
4/15/22 was not likely to have been more beneficial for evaluation of the patients condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures, depending on the patientas symptoms and findings. The exact process depends on the provider and the resources available at that particular office. This patient reported a fishy odor, and the provider noted white discharge on examination. The medical evidence supports the services at issue in this patientas case. The services at issue were standard of care option and are clinically appropriate, especially when the history and examination do not coincide. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy provided from 9/12/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism.  The physician reviewer found that ABA therapy is a medically appropriate intervention for the treatment of autism spectrum disorders, and remains one of the most evidence-based interventions available. In this case, the patient has a diagnosis of autism with repetitive, restricted and/or stereotypic behaviors. The patients maladaptive behaviors interfere with his activities of daily living, making it difficult for him to be successful in more generalized environments. ABA therapy has been recommended for treatment of the patients daily living skills in the areas of independent living, job skills, community skills, self-injurious behaviors, aggression and stereotypical behaviors. Moreover, the provider also recommends training for the parents, and other family members and caregivers that are involved in the patients care. The training is to be focused on increasing independent skills while fading direct and indirect prompts required to complete tasks. Based on the clinical documentation submitted for review, ABA therapy provided from 9/12/16 forward was and is medically necessary for treatment of the patients autism. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has a history of obesity status post gastric bypass and cholecystectomy, who presented with dysphagia. The patient was taken for an urgent cholecystectomy and has had solid food dysphagia since. She describes predominantly solid food dysphagia but does not endorse particular difficulty with liquids. She was taken for an upper endoscopy, which revealed a 3 cm hiatal hernia and angulation in proximity of the surgical intervention, suggestive of possible obstructive process.  The provider seeks surgical revision, given the patientas symptoms of abdominal pain, nausea and vomiting. The requested testing has not been proven to be safe and effective based on well-designed randomized controlled trials and has not been shown to necessarily alter health outcomes. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 32-year-old female enrollee has requested authorization and coverage for bilateral breast reduction surgery. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees macromastia.   The physician reviewer found this patient satisfies the criteria from the American Society of Plastic Surgeons (ASPS) for the requested bilateral breast reduction surgery but not the requested suction assisted lipectomy. In the peer-reviewed medical literature, Coriddi and colleagues noted that documentation of a functional problem can be demonstrated with evidence of intertriginous infections, back and shoulder pain, shoulder notching, physical inactivity, dissatisfaction with breast appearance, poor sexual well-being, and poor psychosocial well-being. This patient has well-documented chronic back pain, neck pain, shoulder pain, breast pain, shoulder grooving, and intermittent intertrigo with failure of topical medical management and other reasonable conservative management including analgesics. Further, her symptomatic macromastia has failed reasonable conservative management. Her photographs are supportive of her clinical functional deficit. Based on this, her condition of macromastia is causing functional problems that would benefit significantly from reduction surgery. All told, breast reduction is well-known to be safe in the carefully selected patient and is appropriate based on the ASPS criteria for this patient. However, this is not the case for suction assisted lipectomy which is generally performed to improve the aesthetic appearance of the breasts. Based on the foregoing discussion, a portion of the requested services is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.