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

Summary Reviewer 

A 34-year-old female enrollee has requested authorization and coverage for Xyrem 500 mg/ml oral solution. 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 there is sufficient support for the requested services in this clinical setting. The patient was accurately diagnosed with narcolepsy without cataplexy. Her symptoms were not controlled with several stimulant medications. The patient has excessive daytime sleepiness, which responded to Xyrem. Xyrem has been approved by the U.S. Food and Drug Administration for the treatment of patients with narcolepsy type 2. Continuation of Xyrem treatment is critical to control this patients narcolepsy. Therefore, Xyrem 500 mg/mL oral solution is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 23-year-old transgender female enrollee has requested reimbursement for facial feminization surgery provided on 11/01/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the current medical evidence supports the medical necessity of the services at issue. The services at issue were likely to have improved the patients psychological and social functioning. Per World Professional Association for Transgender Health (WPATH), medically necessary gender affirming/confirming surgical procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, genital reconstruction, facial hair removal and certain facial plastic reconstruction. This patient has a documented history of gender dysphoria and has been on hormone therapy. Based on the documented history of gender dysphoria, facial feminization surgery was medically necessary for the treatment of this patient. Thus, facial feminization surgery provided on 11/01/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were 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 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that there is a lack of medical literature supporting the service at issue in this clinical setting. Silverstein and colleagues studied intraoperative radiotherapy for early-stage breast cancer. The study revealed that intraoperative radiotherapy was associated with a nine-fold increase in ipsilateral breast recurrence, although five-year overall survival was similar. In addition, the American Society for Radiation Oncology (ASTRO) consensus guidelines recommended intraoperative radiation therapy for those with suitable criteria with invasive cancer, and not for patients with DCIS. Moreover, treatment with intraoperative radiation therapy is not the standard therapy for breast cancer. Given the lack of support in the peer-reviewed literature, the intraoperative radiation therapy performed on 7/19/16 was 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 service 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: Upheld

Summary Reviewer 3


A 61-year-old male enrollee has requested authorization and coverage for intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures). The Health Insurer indicates that the requested services are investigational for the treatment of the enrolleeas medical condition. Therefore, the Health Insurer has denied coverage for the requested services. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that the current medical evidence fails to demonstrate the superior efficacy of the requested services. There is a lack of support for intraoperative monitoring during a single-level lumbar fusion with pedicle screw placement. The cited articles discuss that the use of neural monitoring is associated with a higher cost without significant decrease in complication rate. Single-level lumbar fusion is below the spinal cord level, and neural monitoring is not recommended based on high-quality research. Therefore, intraoperative EMG monitoring and neuromuscular junction testing during spinal surgery (including anterior cervical procedures) is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The patient is a 59-year-old male with a history of prior bilateral renal oncocytomas.  The patient has requested reimbursement for cryoablation for kidney mass performed on 11/06/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. The patient had a renal tumor (oncocytomas) that was a stage T1 lesion. The patient declined active surveillance. The patient was not an appropriate surgical candidate for nephrectomy or partial nephrectomy, given the history of recurrent oncocytomas. The tumor was not an angiomyolipoma. Radiofrequency cryoablation of the renal tumor is supported in this clinical scenario. The medical literature has demonstrated renal cryoablation to have similar or improved outcomes compared with nephrectomy. The studies consistently showed a lower decline in glomerular filtration rate with renal cryoablation. Therefore, cryoablation of the renal mass on 11/06/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15.  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 severe scleroderma. The physician reviewer found the submitted documentation establishes the medical necessity of the services at issue. This patient presents with scleroderma leading to flexion contractures of his extremities, with resultant decrease in ability to perform activities of daily living and maintain normal function. The difficult part of treating these contractures is that he has significant skin fragility due to the scleroderma. He has progressed in inpatient therapy, but it is felt that he needs more time to reach his goals. In this clinical setting, it is medically necessary for the patient to remain in inpatient rehabilitation due to the issue of the skin fragility. He is getting assessments multiple times a day for skin breakdown, and coordinated care between therapists, nursing staff, and physicians to ensure that his skin is dry and intact. He is currently receiving constant adjustments in his splinting and casting to ensure maximum benefit without breakdown of the skin. The risk of not treating this patient in an inpatient setting is worsening of hand function and skin breakdown leading to infection or chronic pain. As such, inpatient rehabilitation treatment provided from 8/27/15 through 9/25/15 was and is medically necessary for treatment of this patients medical condition. For the reasons provided, 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 1

A 57-year-old male enrollee has requested gene testing performed on 9/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found that the testing performed in this case is a study of 15 to 31 genes in an individuals melanoma cells. It has been used to classify that melanoma as having either a high or low risk of metastasis. Per the medical evidence, this testing is particularly useful in the analysis and clinical follow-up of uveal melanoma. This has been validated in several studies and has become a standard test in this setting. Its clinical value lies in determining the need for intense surveillance and possibly to assist in the decision as to adjuvant therapy. Thus, gene testing performed on 9/11/17 was likely to have been more efficacious 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this patients case. The blepharoplasty was not medically necessary based on the lack of appropriate visual field information. The visual fields provided were threshold tests in grayscale format. In order to determine superior eyelid scotoma, a suprathreshold static visual field is required. The provided fields did not demonstrate absolute superior scotomas, and printed results were in grayscale representation only, rather than the numerical visual field test results. This is not a reliable or appropriate visual field test to demonstrate superior visual field loss due to eyelid obstruction. Therefore, upper eyelid blepharoplasty performed on 12/07/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 36-year-old male enrollee has requested reimbursement for monitored anesthesia provided during a colonoscopy on 4/30/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia 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 3
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 polymerase chain reaction testing has been compared to traditional testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it results in significantly higher sensitivity and negative predictive value than clinical diagnosis or clinical testing.  The test was also superior for detecting more than one cause for vaginitis. The medical evidence supports polymerase chain reaction testing as a means of accurate detection which allows for appropriate treatment. 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: Experimental
Decision: Upheld

Summary Reviewer 1


The parent of a 14-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Providers utilize the testing at issue as a standard therapy after starting infliximab to judge whether someone will benefit from the drug. It lets the provider know if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This can help guide the provider in dosing or may lead to discontinue the drug if the patient is not likely to benefit from the medication. This can not only prevent the patient from having a flare, but save them from potential side effects of a drug they may not benefit from. The patient may be exposed to the drug unnecessarily without using this testing. Knowing this before a flare-up occurs can save the patient from a potential inpatient hospitalization as well. All told, the testing at issue was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 44-year-old male with a history of hypothyroidism that is complicated by weight gain and hypercholesterolemia.  The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that hypothyroidism is a common condition of thyroid hormone deficiency, which is readily diagnosed and managed but potentially fatal in severe cases if untreated. Synthetic thyroid hormone (levothyroxine) is the standard of care for patients with hyperthyroidism. Thyroid ultrasonography has established itself as a popular and useful tool in the evaluation and management of thyroid disorders. Indications for thyroid ultrasound include confirmation of the presence of a thyroid nodule, differentiation between benign and malignant masses, to assess for the presence of postoperative residual or tumor, to screen for patients at high risk for thyroid malignancy, and to provide information to help guide interventional procedures, such as a fine-needle aspiration biopsy. There is currently, however, no indication for routine thyroid ultrasound for patients with history of hypothyroidism alone. Therefore, 76536 (ultrasound, soft tissues of head and neck, real time image) performed on 1/27/21 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 31-year-old female enrollee has requested authorization and coverage for Uceris 2 mg rectal foam. 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 requested medication in this clinically setting. This patient has left-sided ulcerative colitis based on colonoscopy and recent computed tomography scan. Budesonide foam primarily works in the rectum and left colon. American College of Gastroenterology guidelines for the treatment of ulcerative colitis state that colonic delivery of budesonide offers more directed therapy and fewer systemic side effects than alternatives (given the high first-pass hepatic metabolism of budesonide), and that in patients with moderately active ulcerative colitis, non-systemic corticosteroids such as budesonide should be considered before the use of systemic therapy. The guidelines also recommend the use of topical rectal therapy before systemic therapy in distal colitis. Studies of budesonide foam have shown minimal systemic adverse effects, and that budesonide foam is well-tolerated and effective. A double-blind randomized trial by Naganuma and colleagues demonstrated effectiveness of budesonide foam in distal ulcerative colitis. Budesonide foam is supported as safe and effective for the treatment of distal colitis. Therefore, Uceris 2 mg rectal foam is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 53-year-old female enrollee has requested authorization and coverage for a transcatheter aortic valve replacement (TAVR). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has severe aortic stenosis and requires valve replacement. She has a bicuspid valve, and given her age, she would likely need at least two chest surgeries owing to bioprosthetic valve degeneration over her lifetime. Her providers would like to initially attempt TAVR to obviate the need for surgical valve replacement at least until she reaches her 60s. TAVR has been studied and used successfully in low risk patients in a number of randomized published trials and carries an U.S. Food and Drug Administration (FDA) approval for this indication. The risk/benefit has been carefully weighed by the treating providers and the patient and an initial plan for non-surgical TAVR was made using the heart team and a shared decision making model based on AHA/ACC recommendations. There is support for the requested services in this clinical setting. Therefore, the requested TAVR is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the breast tomosynthesis performed on 8/20/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. In this case, the patient presented for a breast cancer screening with tomosynthesis. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, there is support for the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 59-year-old male enrollee has requested reimbursement for substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 6/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that this patient was on a potentially life threatening detoxification from phenobarbital. Phenobarbital has a rather low LD50, and the patient demonstrated that he was unable to refrain from overuse of this and other substances, suggesting that he was at high risk for overdose if detoxification was not conducted in a controlled environment. As such, medically conducted detoxification was appropriate until the doses of his phenobarbital were brought down to minimal levels. The records indicate the patients phenobarbital levels were safely at minimal levels by 5/11/16. Thus, by 5/12/16 he could have been stepped down to chemical dependency partial hospitalization program (CD-PHP) treatment. For these reasons, the substance abuse residential detoxification and rehabilitation services provided from 5/5/16 through 5/11/16 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 58-year-old male enrollee has requested authorization and coverage for posterior cervical disc fusion C2-T2 and two bed days. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records document a history of severe neck pain associated with radiculopathy as well as myelopathy and a probable pseudarthrosis at C7-T1 and cervicothoracic kyphosis. There is a history of prior anterior and posterior cervical fusion. The provider is requesting revision surgery from C2 to T2 posteriorly. Loosening of the pedicle screws at C7 and intra-facet placement of the C3 screws are documented. Per the literature, instability of the cervicothoracic junction is fairly common after a long cervical fusion. In the study by Truumees and colleagues, a total of 177 adult spine patients undergoing three or more levels of posterior cervical fusions for degenerative disease were included. According to this study, extension of the posterior cervical fusion into the thoracic spine leads to a lower pseudarthrosis rate. Furthermore, correction of the cervicothoracic kyphosis will also be necessary to relieve pain. Additionally, the proximal extension of the posterior construct to C2 is also necessary for stability in this long construct and for revision of the proximal intra-articular pedicle screws described by the provider. Therefore, posterior cervical disc fusion C2-T2 and two bed days are medically necessary for the treatment of this patient.