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

Summary Reviewer 2


A 62-year-old male has requested authorization and coverage for cervical total disc arthroplasty.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain and radiculopathy of arm. The physician reviewer found the evidence-based medical guidelines and peer-reviewed literature do not support the use of an artificial disc replacement adjacent to a prior anterior cervical discectomy and fusion and in the setting of multilevel degenerative disc disease.  This patient presents with progressively worsening neck pain with right upper extremity radiculopathy in the C5 distribution.  Functional limitations were documented in activities of daily living and work activities.  Detailed evidence of a recent nonoperative treatment protocol trial and failure has been submitted.  Clinical examination findings were consistent with reported imaging evidence of nerve root compression at the C4-C5 level.  He was status post C5-C6 anterior cervical discectomy and fusion with adjacent segment disease at the C4-C5 and C6-C7 levels.  In sum, the requested cervical total disc arthroplasty is not likely to be of greater benefit than other treatment alternatives.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that this patient has hormone receptor positive breast cancer that has metastasized to her bones, nodes, and lung. She has already been treated with an aromatase inhibitor. Ibrance in combination with Faslodex is considered a standard of care for patients with metastatic hormone positive breast cancer after progression on an aromatase inhibitor as this patient. Ibrance is also supported by the National Comprehensive Cancer Network (NCCN) guidelines as well as U.S. Food and Drug Administration (FDA) approved for this indication. For these reasons, the requested Ibrance 100 mg is 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 medication is 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 

The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program services from 5/21/19 forward. The Health Insurer has denied this request and reported that the services at issue were not and are 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 given her reported history of physical abuse and poor social skills. In terms of functional status, the records support a score of 2 based on her history of the suspension from school and conflict in the home environment. In terms of comorbidity, the records support a score of 2 due to poor social skills and emotional expression for her chronological age without current medical illness. With regards to level of stress of the recovery environment, the records support a score of 3 due to the death of her ex-boyfriend prior to the start of treatment and her sisters car accident during treatment, as well as her sisters cannabis use. In terms of level of stress of the recovery environment, the records support a score of 3 due to the parent stating that she was giving up on parenting the patient in a family therapy session on 6/05/19. With regards to resiliency and treatment history, the records support a score of 3 due to having been in a residential treatment center for 17 months and continuing to decline in functioning since returning home. In terms of acceptance and engagement of the patient, the records support a score of 3 since the patient refused to speak in groups after 5/21/19. With regards to acceptance and engagement of the parent, the records support a score of 3 due to the parent stating in family therapy that she was done parenting the patient. Therefore, the patient has a composite score of 21. Mental health intensive outpatient program services were and are appropriate in this clinical setting. Thus, mental health intensive outpatient program services from 5/21/19 forward were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 50-year-old male enrollee has requested authorization and coverage for transcatheter insertion of permanent leadless implantable pacemaker. 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 current medical evidence has not established the superior efficacy of the requested services. Leadless pacing systems have utilized a self-contained system that includes both the pulse generator and the electrode within a single unit that is placed into the right ventricle via a transvenous approach. One system is now U.S. Food and Drug Administration (FDA) approved and commercially available. However, placement of a leadless cardiac pacemaker may lead to right ventricle dysfunction and may contribute to worsening tricuspid regurgitation. Longer term follow-up is needed to assess the safety and efficacy of these devices. Therefore, transcatheter insertion of permanent leadless implantable pacemaker is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 64-year-old female who was diagnosed with rectal cancer in 2016. This patient was diagnosed with localized (T3N0M0) squamous cell cancer of the rectum. The patients provider sent a sample tissue for molecular testing which was initiated on 2/28/17. The patient has requested reimbursement for CarisMI profile testing services performed on 3/10/17. The Health Insurer denied this request on the basis that the services at issue were investigational for the evaluation of this patients medical condition. In this case, the services at issue were not likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. This patient has localized (T3N0M0) squamous cell cancer of the rectum. Expanded genomic profiling panels are not considered standard testing to assist in managing and directing treatment. Standard therapy incudes local therapy, surgery and radiation, with or without chemotherapy. The standard of care for patients diagnosed with squamous cell cancer is targeted therapy hence the extensive genomic panel ordered including immunohistochemistry would not have been indicated in this clinical setting.  In addition, next generation panels may prove useful after failure of the standard of care, primarily to help identify new potentially actionable targets and/or for clinical trial purposes. However, obtaining expanded next generation testing at diagnosis is not reflective of the clonal evolution at relapse or disease refractoriness. In sum, the CarisMI profile testing services performed on 3/10/17 were not likely to be more effective than the standard methods of evaluating this patients medical condition. Therefore, for the reasons stated 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old female enrollee has requested reimbursement for residential treatment center services provided from 2/20/15 through 11/23/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  At the time of admission, the patient had been referred from a wilderness program.  She was described as labile, and lacking in insight and coping skills despite over two months in the wilderness program.   Although she denied active suicidal or homicidal ideation, the patient was a danger to herself and others based on her emotional dysregulation and acting out behavior.  She was labile, easily triggered, and extremely unpredictable.  By 4/14/15, she was less labile, more firmly engaged and appropriate in her interactions in group, individual, and family therapies, and gaining insight into her behavior.  At that point, there was not a high likelihood of her requiring acute hospitalization were she not to be in residential treatment.  Although the patient required continued intensive treatment in a highly structured environment, she did not necessitate 24-hour supervision at residential level.  Although later into the residential stay, she demonstrated rageful outbursts, once she was at what appeared to be this plateau, it would be difficult to predict any future event and keep her at a higher level of care in anticipation of such an event which may or may not occur.  All told, residential treatment center services provided from 2/20/15 through 4/14/15 were medically necessary, but not thereafter.  Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 2/6/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the patient has left sided ulcerative colitis disease and has been maintained on Remicade since August 2013. However, she had incomplete response as documented clinically despite being maintained on Remicade. Hence, in the midst of this course, while on adequate therapy, an IFX test was ordered to check for Remicade that would necessitate considering alternate therapy. Thus, the indication for the IFX test was the patients ulcerative colitis and incomplete response being on adequate treatment with Remicade and ruling out alternate causes complicating this course. In this case, the IFX test was indicated due to the multitude of management options once a patient has no response to Remicade and the fact that Remicade has a wide array of adverse effects, it is important for the treating provider to have a roadmap of the nature of the patients clinical course. Therefore, the Prometheus Anser IFX testing performed on 2/6/14 was likely to be more beneficial for evaluation and treatment of the patients ulcerative colitis 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for laboratory services provided on 8/15/19. The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that individualized molecular tumor profiling holds the promise of enabling personalized selection of molecularly targeted treatment based on the specific genotype identified. The National Comprehensive Cancer Network guidelines recommend tumor molecular testing prior to initiation of therapy for recurrent or persistent ovarian cancer, if not previously done. Testing should include at least BRCA1/2, homologous recombination pathway genes, and microsatellite instability or DNA mismatch repair. Knowing if a patient has a somatic mutation in a BRCA gene helps select maintenance therapy after primary treatment. Molecular profiling is now considered a standard of care in patients with ovarian cancer. Therefore, laboratory services provided on 8/15/19 were likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 4/11/18 forward. 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 in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively suicidal and did not engage in self-harm. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and oppositional behaviors but overall showed appropriate daily functioning while in treatment as evidenced by intact activities of daily living, cooperation with treatment and good school performance. With regards to comorbidity, the records support a score of 2. The patient did not have a history of past medical issues and had some past substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have good relationship with his family and denied current stress at home of any significant nature. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history. The records support a score of 2. The patient reported improved symptom presentation while at the residential treatment center and was participating in therapy programming while on the unit. He was not displaying serious or disruptive symptoms. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy and indicated trust in his therapist. 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 has a composite score of 15. This score correlates with outpatient services. Therefore, residential treatment from 4/11/18 forward was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 58-year-old female enrollee has requested authorization and coverage for Ibrance 100 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees breast cancer.  The physician reviewer found that Ibrance inhibits Cyclin-dependent kinases 4 and 6 (CDK4, CDK6), which may account for resistance to endocrine therapy and has been U.S. Food and Drug Administration (FDA) approved for first-line therapy of estrogen receptor (ER) positive, HER2 negative metastatic breast cancer in postmenopausal women in combination with letrozole. Turner and colleagues reported that in the PALOMA-1 trial, 165 patients were randomized to letrozole or letrozole with Ibrance and the latter regimen conferred increased progression-free survival of 20.2 months versus 10.2 months, a finding of high statistical significance. Overall, there is sufficient medical evidence to suggest that Ibrance is appropriate for this patient who has progressed on standard regimens. As such, the requested Ibrance 100 mg is 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 medication is 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: Upheld

Summary Reviewer 

The patient is a 40-year-old female with a history of psychosis, mood instability and diagnosis of bipolar affective disorder. The patient has requested reimbursement for inpatient services provided from 6/25/20 through 7/02/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Although the patient met medical necessity criteria for inpatient level of care upon her initial presentation on 6/11/20, she had stabilized significantly by 6/25/20. As of 6/26/20, she was noted to be well-groomed, her mood was happy, and she had less thought blocking. At this point, she could have been discharged to a lower level of care. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. In terms of risk of harm, the records support a score of 2. The patient had a low risk of harm given lack of suicidality. She did endorse situation passive suicidal ideation upon learning of discharge. With regard to functional status, the records support a score of 3. The patient was disabled from mental illness and could not work. She had some disturbance in eating and sleeping habits, although they were improving. In terms of comorbidity, the records support a score of 2. The patient had minor medical comorbidity and had no substance abuse problems. With regard to level of stress of the recovery environment, the records support a score of 2. The patientas recovery environment was mildly stressful. She is away from family on the East Coast and more isolated due to COVID-19. Her husband is supportive. In terms of level of support for the recovery environment, the records support a score of 2. The patient had an outpatient psychiatrist and is able to advocate for her needs. With regard to treatment history, the records support a score of 2. The patient has had good response to outpatient treatment in general and her last inpatient hospitalization was 2015. In terms of engagement, the records support a score of 2. While inpatient, the patient had been adherent with treatment plan, including medication. Therefore, the patient has a composite score of 15. Thus, she did not meet criteria for inpatient level of care. All told, inpatient services provided from 6/25/20 through 7/02/20 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 38-year-old male enrollee has requested authorization and coverage for Praluent 75 mg/mL pen, 75 mg injected subcutaneously once every two weeks. 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 fails to demonstrate the medical necessity of the requested medication. In this patients case, there is no documented clinical cardiovascular disease. He has mild hyperlipidemia while on pravastatin and ezetimibe. In this circumstance, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is not medically necessary.  Praluent is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit any of those criteria.  There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. PCSK9 inhibitors have not been studied in other patient populations. The current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, Praluent 75 mg/mL pen is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 42-year-old male enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back and left lower extremity pain.   The physician reviewer found that evidence based clinical practice guidelines for performing radiofrequency neurolysis are consistent with the treatment plan following this patients care (Manchikanti, et al). It is important to note that radiofrequency neurolysis is not permanent as the nerves re-grow. Typically, the lesions produce up to one year of pain relief (Choi, et al). Given that this patients provider followed the treatment paradigm for managing this patients care and properly administered medial branch blocks with the previous radiofrequency ablation, the requested repeat radiofrequency ablation is likely to provide this patient with a superior health outcome as compared to standard available treatment options. 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.