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

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees chronic low back pain. The physician reviewer found that the requested spinal cord stimulator is not medically necessary in this clinical setting. The records provided do not have spine pain targeted in the dermatomal distribution that may be treated with spinal cord stimulation. Additionally, there is no psychological evaluation. Finally, the records do not indicate that this patient has tried and failed all forms of treatment including surgery. There is not a surgical consultation documenting that the patient is a not surgical candidate. Per Block and colleagues, Back pain is experienced by up to of 85% of the United States population. Most often it resolves with minimal to no medical treatment. For those whose pain endures, worsens, or becomes protracted, conservative care is typically first attempted. Individuals who continue to experience significant back pain are often considered for surgical procedures, the results of which are not uniformly positive. Current peer reviewed, medical literature demonstrates the spinal cord stimulator to be indicated for severe, highly debilitating conditions for which this patient has not been shown to have. 
Based on the medical documentation presented for review, the patient does not have severe paralysis or complex regional pain syndrome for which this treatment modality is better suited. Based on current peer reviewed medical literature and in consideration of the submitted clinical records, the spinal cord stimulator trial is not medically necessary or the standard of care. The standard of care for treatment of the patients condition includes anticonvulsant, antidepressants, and opioid medications targeting neuropathic pain. As such, the spinal cord stimulator is not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 65-year-old female enrollee has requested reimbursement for collagen crosslink testing and homocysteine testing provided on 12/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has been diagnosed with osteoporosis. She has received treatment with Forteo, followed by Tymlos. As part of management, her endocrinologist has ordered collagen crosslink testing and homocysteine testing. The use of markers of bone turnover is standard practice among endocrinologists and other specialists in osteoporosis and is a tool to monitor therapy. Collagen crosslinks are bone turnover markers that are used as a guide to monitor compliance and efficacy of treatment. They also help to identify non-responders that require additional work-up for other causes of osteoporosis. The medical evidence indicates that the principal clinical utility of bone turnover markers is for monitoring therapy. In this case, the patients provider is using the information from this test result to help establish whether the patient has responded to therapy and determine follow-up therapy after anabolic treatment with Tymlos and Forteo. Regarding homocysteine, it is a marker of oxidative stress and it has been found to be elevated in osteoporosis. Studies have found a direct correlation of homocysteine levels and bone loss. High serum homocysteine may be regarded as a factor that can reduce both bone mass and impair bone quality. It will help in the determination of the prognosis and need for additional therapy. In sum, collagen crosslink testing and homocysteine testing provided on 12/03/18 were likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that at this time, there is insufficient data to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. In this case, the patient has cervical spondylosis with foraminal impingement at the C5-6 and C6-7 levels. In this clinical setting, the standard procedure is a single level anterior cervical discectomy and fusion. In addition, the use of total disc arthroplasty in the setting of spondylosis with foraminal compromise by disc osteophyte complex and degenerated disc remains controversial.  Given the above, the requested neck surgery 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 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: Upheld

Summary Reviewer 

A 21-year-old male enrollee has requested reimbursement for buprenorphine 74.2 mg implant provided on 9/29/18. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The medical records indicate the patient received two doses of the requested Probuphine as of 8/22/18. The current evidence indicates that standard treatment with this medication is two doses. Additional doses are not indicated per the medical literature. Therefore, buprenorphine 74.2 mg implant provided on 9/29/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 61-year-old male enrollee has requested authorization and coverage for Dulera 100 mcg/5 mcg inhaler. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that Asthma is a prevalent disease and management guidelines have been laid out by the collaborative Global Initiative for Asthma (GINA) since 1993. The role of combination inhalers is to better manage patients who have breakthrough symptoms on low doses inhaled steroids. There are at least five separate combination inhalers, available in both dry powder and metered doses. To date there are no comparative studies between the drugs as the compounds in them are either identical or in the same chemical family. Maspero and colleagues evaluated the long term safety and efficacy of Dulera in patients inadequately controlled by Advair. A total of 404 patients were randomized to Dulera versus Advair. They evaluated for adverse events over 52 weeks. Along with this, pulmonary function, asthma symptoms and the use of rescue medications were monitored. In all, there were no differences between the combination inhalers in rates of adverse events or the other monitored variables. In the study by  Meltzer and colleagues, they evaluated 746 subjects receiving either placebo, Dulera or the individual components over 26 weeks and the co-primary end point was timed to the first asthma deterioration and change in forced expiratory volume in 1 second (FEV1). The study found that Dulera lead to a significant reduction in the rate of asthma deterioration and time of first exacerbation along with an improvement in measured health related quality of life.  However, there appears to be no demonstrable difference between combination inhalers in regards to asthma control, in particular Dulera and Advair, one of the combination inhalers covered by the Health Insurer. Under the circumstances of this case, the patient appears to prefer the use of a metered dose inhaler to the dry powder inhaler. However, he does not have any evidence of worsened asthma control aside for clinical complaints. There are no provider notes or calls to the office, no prednisone prescriptions for exacerbations or no emergency department visits/hospital admissions. The documentation provided does not note an objective worsening of control while using effectively identical medications. As such, this patient already has the option of a metered dose inhaler (Advair HFA) that is proven to be equally efficacious as Dulera. In sum, Dulera 100 mcg/5 mcg inhaler is not medically necessary for the treatment of this patients medical condition. Therefore, for the reasons stated above, the requested medication is not medically necessary for the treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for mental health residential treatment from 7/17/17 through 9/16/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. The progress notes indicate that the patient was not engaging in self-harm behaviors or expressing suicidal ideation. She did have a history of suicidal ideation and attempts. In terms of functional status, the records support a score of 2. The patient has had some issues with level of functioning, but the progress notes indicate significant improvement after a period of deterioration as evidenced by appropriate activities of daily living and grooming. With regards to comorbidity, the records support a score of 2. The patient did not have active medical problems and reported a history of mild cannabis use issues.  She did not describe continued cravings, and there was no documentation of withdrawal symptoms from substances. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with the family as a focus of treatment. However, the progress notes document that her family therapy sessions were productive and not adversarial. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. The patient had good response to a short period in the residential treatment center prior to the disputed dates. Her presentation during the disputed timeframe indicates that she was cooperative in treatment. She had a history of residential treatment in the past, and it is not clear that her symptoms resolved with past treatment efforts. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively and was able to develop a positive relationship with clinicians. In terms of acceptance and engagement of the parent, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient had a composite score of 17. This score correlates intensive outpatient services. Therefore, mental health residential treatment provided from 7/17/17 through 9/16/17 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested authorization and coverage for a power wheelchair. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found The request for a power wheelchair is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient presents with Friedreichs ataxia which is an inherited autosomal recessive disorder characterized by central nervous system damage to the spinal cord, cerebellum, and medulla, manifest as slowly progressive ataxia. Ataxia involves the lower extremities more than the upper extremities. Patients also exhibit characteristic explosive dysarthric speech and nystagmus. There may be weakness of the distal musculature, progressive kyphoscoliosis, loss of vibration and position sense, and progressive hypertrophic cardiomyopathy. Cognitive function is generally intact. Patients with severe disabilities requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications and optimizing independence. In this case, the patients disabilities necessitate specialized equipment to allow for functional mobility, social and therapeutic interactions, and preparation for transition to adulthood. She is no longer able to maneuver her manual wheelchair despite modifications, limiting her mobility. A power wheelchair is medically necessary to allow her to move throughout her environment, functioning as independently as her physical limitations will allow. For the reasons stated, the requested power wheelchair is indicated for this patient. Therefore, the requested services are 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 51-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 1/18/21. 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  prognostic  gene  expression  profiling  (GEP)  testing  to  differentiate 
melanomas  at  low  versus  high  risk  for  metastasis  should  not  replace  pathologic  staging 
procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a 
higher proportion of false-positive result, GEP testing should not guide clinical decision making 
in this group. Commercially available GEPs, such as DecisionDx-Melanoma testing, are marketed 
as  being  able  to  classify  cutaneous  melanoma  into  separate  categories  based  on  risk  of 
metastasis.  However,  it  remains  unclear  whether  these  GEP  platforms  provide  clinically 
actionable prognostic information when used in addition to or in comparison with known 
clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor 
location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph 
node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up 
schedules has not been established. Various (mostly retrospective) studies of prognostic GEP 
testing suggest its role as an independent predictor of worse outcome, although not superior to 
Breslow thickness or sentinel lymph node status. It remains unclear whether this GEP profile is 
reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation 
studies are required to more accurately define the clinical utility of molecular testing prior to 
widespread  implementation  of  GEP  for  prognostication  of  cutaneous  melanoma,  and  in 
particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and 
adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 1/18/21 
was not likely to have been more beneficial than other available methods of evaluating this 
patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

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 Anser IFX testing performed on 2/24/15 was not likely to be more effective for this patient than other available options. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies, and the Anser ADA test assesses serum adalimumab (ADA) and anti-ADA antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or adalimumab or the presence of IFX or ADA antibodies have an adverse effect on the clinical outcome of a patients response to treatment. While however there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). In sum, it has not yet been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Given the above, 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested authorization and coverage for Fentora buccal tablets 800 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain associated with spine degenerative disc disease and/or post-laminectomy syndrome is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  High-dose opioids are associated with a high risk of dependence and tolerance.  Baron and McDonald reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Ballantyne and Mao reported that prolonged use of high-dose, short-acting opiates might induce tolerance and abnormal pain sensitivity.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, Fentora buccal tablets 800 mg are not medically indicated 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. 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 that in this case, the 3D mammogram was clinically indicated for this patient. The patients breasts are described as extremely dense. It is specifically those patients who have dense breasts that can benefit most from 3D mammogram. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. In addition, the patient presented with a palpable lump. Once a lump is palpated, it is imperative to determine whether a mass is present. For the reasons provided, the 3D mammogram provided on 10/31/16 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 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  
The patient is a 24-year-old male who was admitted to the hospital on 5/17/21 with pleuritic 
chest pain and low-grade fever. The patient has requested reimbursement for inpatient hospital 
stay from 5/17/21 to 5/18/21. The physician reviewer found that Myocarditis has been described 
following COVID-19 mRNA vaccinations in young adults, particularly males. The patient had fever 
and a persistent tachycardia in the setting of significant troponin elevation and was appropriately 
hospitalized to monitor for arrhythmias and/or congestive heart failure, as well as heparin drip 
monitoring  which  was  initiated  on  admission.  Hospitalization  can  be  necessary  if  clinical 
instability is noted by virtue of unexplained tachycardia, which could indicate heart failure. The 
medical evidence supports the services at issue in this clinical setting. Therefore, the inpatient 
hospital stay from 5/17/21 to 5/18/21 was medically necessary for the treatment of this patient.