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

Summary Reviewer

The patient is a 47-year-old male with Crohns disease. Per the providers note dated 3/15/18, the patient was diagnosed in 2000 and has failed prednisone, Entocort, Cipro, Flagyl, Xifaxan, Pentasa, 6-mercaptopurine, methotrexate, and Remicade. He has had a temporary ileostomy, bowel resection, ileocecectomy in 2000, and takedown surgery. The patient started Humira every 14 days and then every seven days in 2005, which healed his anal fistulas. He was on Humira 80 mg every seven days since mid-January 2018 but was later switched back to Humira 40 mg every seven days with concurrent methotrexate and Entocort. A colonoscopy on 3/2/18 showed recurrence at the anastomosis and neo-terminal ileum. The note states that the patients Humira level was 26 with negative anti-Humira antibody testing, and that Stelara infusion was given on 3/13/18. The patient was having mild intermittent bleeding but no abdominal pain. The patient has requested authorization and coverage for Humira injections 80 mg every seven days. The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary. The use of Humira 40 mg more frequently than every 14 days is supported in the medical literature to prevent disease complications. In the CHARM trial, which was a high-quality phase III randomized double-blind placebo-controlled 56-week study, 27% of open-label patients required dose escalation with weekly dosing (Colombel, et al). The remission rate with weekly dosing was reported at 46.9% versus 22.5% when dosing every other week (Sandborn, et al). The use of Humira more frequently than every 14 days is supported by current medical literature, and preferred to changes to a different therapy, which may result in loss of disease control (Van Assche, et al). The consequences of uncontrolled disease can include disease flare, inflammation related sequelae such as the development of a fistula, stricture, or abscess, and the need for hospitalization or surgery. The records indicate that this patient failed Humira 40 mg dosed every seven days, and had improvement with Humira 80 mg dosed every seven days. For these reasons, the request for Humira 80 mg every seven days is supported as medically necessary for the treatment of the patients Crohns disease.  Based on the foregoing discussion, the requested medication dosage is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 10-year-old male with a history of short stature and suspected pediatric growth 
hormone  (GH)  deficiency  related  to  optic  nerve  hypoplasia  (ONH).  The  provider  has 
recommended treatment with GH therapy. The Health Insurer has denied the requested treatment 
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 this patients records 
document a history of short stature with a previous diagnosis of ONH, which is a congenital 
disorder of midbrain development that can be associated with hypopituitarism. However, this 
patients records lack documentation confirming a diagnosis of ONH by MRI, genetic testing, 
and/or dilated ophthalmic examination. There is also a lack of evidence of anterior pituitary 
hormone deficiencies or intracranial lesions. As noted in the medical literature and current 
guidelines, the essential diagnostic criterion for idiopathic short stature is a height z-score -2.25 
standard deviations below the mean (Grimberg, et al.). The available records indicate that this 
patient has not met this essential diagnostic criterion, because his height has been within normal 
range with a z-score between -2.0 and +2.0. Based on the patients normal bone age, normal recent 
height, and chronological age, the patients predicted adult height was reported as 174.9 cm, 
estimated within 3.1 cm. This predicted adult height is within the normal range for age and gender 
and within two standard deviations of the patients estimated MPTH of 72.5 inches. There is a lack 
of documentation indicating the patient underwent GH provocative tests to support the diagnosis 
of pediatric GH deficiency. Moreover, direct height measurements of both biological parents are 
preferred to evaluate suspected growth disorders in pediatric endocrine care, as self-reported 
parental heights can be unreliable. Overall, the patient does not meet the U.S. Food and Drug 
Administration (FDA) requirements for any approved indications for GH therapy. For these 
reasons, the requested Norditropin 10 mg/1.5 mL pen injector is not medically necessary for 
treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 10/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for purposes of the enrollees breast cancer screening.  The physician reviewer found there is limited peer-reviewed literature that supports the use of three dimensional breast tomosynthesis compared to currently available techniques, especially in a patient without an increased risk of breast cancer. While the technology is promising, its clinical efficacy has not yet been substantiated in peer-reviewed literature. At this time, there is insufficient data from randomized, controlled studies demonstrating that the addition of breast tomosynthesis to standard mammography results in improved outcomes in this patient population. Therefore, the superior effectiveness of breast tomosynthesis performed on 10/29/15 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 20-year-old male enrollee has requested reimbursement for residential treatment services provided from 3/22/18 through 3/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) provides a framework for determining the appropriate level of care in patients with mental health treatment needs. With regard to risk of harm, the records support a score of 3. The patient had a history of chronic impulsive suicidal/homicidal behavior or threats, but his current expressions did not represent significant change from usual behavior. In terms of functional status, the records support a score of 3. The patient had moderate impairment, due to conflicted and troubled relationships and inability to continue in school. With regard to medical, addictive, and psychiatric comorbidity, the records support a score of 3. The patient had significant comorbidity, due to co-occurrence of traumatic brain injury, substance use disorder, and mood symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to strained relationship with parents, multiple recent transitions, and recent homelessness. With regard to level of support of the recovery environment, the records support a score of 4 due to the patients refusal to participate in treatment and accept support offered by his parents. In terms of treatment and recovery history, the records support a score of 3. The patient had moderate or equivocal response to treatment. With regard to engagement and recovery status, the records support a score of 4. The patient had minimal engagement and recovery, due to reluctance to engage in or complete residential programs, lack of desire to change behavior, and failure to accept responsibility for his own recovery. Thus, the patient has a total score of 23. The recommended level of care is medically monitored residential services. Given the patients impulsivity and limited coping skills, poor insight and judgment, a residential level of care was appropriate for him at the time of his admission and treatment. Therefore, residential treatment provided from 3/22/18 through 3/30/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 65-year-old male with a history of prostate cancer. The patient was initially diagnosed in 2015.  The provider noted that despite an initial excellent response to six cycles of docetaxel chemotherapy, the patients prostate specific antigen (PSA) levels rose. The provider recommended treatment with Cabometyx. The patient has requested authorization and coverage for Cabometyx (cabozantinib) 60 mg #30/30. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of this patients medical condition. The use of cabozantinib for prostate cancer is not U.S Food and Drug Administration approved and is not supported by major drug compendia for off-label use. A phase III clinical trial, COMET-1, has not shown a benefit in overall survival. Another phase III trial combining cabozantinib with mitoxantrone was discontinued after the results of COMET-1. The use of molecular profiling to match molecular mutations with clinical trials is still ongoing. Therefore, Cabometyx (cabozantinib) 60 mg #30/30 is not likely to be more beneficial for treatment of this patients medical condition than the available standard therapy. Based upon the information set forth above, the requested medication 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: Overturned

Summary Reviewer 1


A 50-year-old female enrollee has requested reimbursement for Afirma gene testing performed on 7/22/14. 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 that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. While a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). A relatively new test, the Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Based on the support in the peer-reviewed literature and clinical documentation submitted, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than other modalities.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 38-year-old female enrollee has requested authorization and coverage for matrix autologous chondrocyte implantation, up to three days in hospital stay and growth of cartilage from her knee. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees osteochondral defect. The physician reviewer found autologous Autologous chondrocyte implantation techniques require a two-stage procedure, the first for chondrocyte harvest and the second for implantation in a periosteum-covered or matrix-induced form after in vivo culture expansion. The transplantation of chondrocyte-like cells into the defect will result in hyaline-like repair tissue. The medical literature demonstrates that autologous chondrocyte implantation is usually successful in relieving pain in the presence of a large osteochondral defect with minimal degenerative change in the remaining joint. In this case, the patient presents with a large osteochondral lesion of the talus and has failed multiple surgical procedures with continuing pain. Based on the support in the peer-reviewed literature, the request for matrix autologous chondrocyte implantation, up to three days in hospital stay and growth of cartilage from her knee 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for the positron emission tomography (PET) scan provided on 5/10/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees Stage IV ovarian cancer. The physician reviewer found that The findings on the PET/CT from 2/2/16 raised the possibility of tumor and the interpreting provider recommended a follow-up study. Thus, the PET/CT was indicated and complied with the National Comprehensive Cancer Network (NCCN) guidelines which state that PET/CT scan is an accepted tool for use in this clinical setting based upon questionable imaging results. Thus, the PET scan performed on 5/10/16 was medically necessary for further evaluation of this patients possible tumor in the setting of known metastatic ovarian cancer. Based on the foregoing discussion, the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 42-year-old female enrollee has requested reimbursement for supraorbital, occipital and suprascapular nerve blocks of the occipital nerve performed on 10/3/16 and 10/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic headache. 
 The physician reviewer found that Neuralgia is a type of neuropathic pain that can be chronic of paroxysmal, shock, lightening like, burning, dull or ache type pain that follows a peripheral or cranial nerve area and can also spread to other areas. Inherent in the definition there cannot be a neurologic deficit correlating with the nerve affected. Attacks can either be spontaneous or provoked by direct stimulation or palpation of other trigger point zones. Occipital neuralgia can specifically refer to pain and or headache in the occipital region in the greater, lesser, or third occipital nerve areas which can also be accompanied by dysesthesia or decreased sensation in the nerve distribution. On examination, patients would have tenderness with palpation over the occipital area. Another key element to the diagnosis is response to occipital nerve blocks, which this patient also exhibited. The treatment of choice for occipital neuralgia is a local occipital nerve block due to its ability to relieve pain as well as act as a diagnostic marker. Considering the information provided by the provider, this patient has chronic migraine and occipital neuralgia. The treatment that she has received has reportedly provided therapeutic benefit. Moreover, this patient has tried several therapeutic options for her condition without any benefit and with some documented adverse effects. 
This patient meets the criteria for chronic migraine. She has a long history of chronic migraine and failure with several treatment modalities. Included in that history of failure, the majority if not all prophylactic and abortive therapeutic options were discontinued due to lack of effectiveness. There are various studies with evidence to suggest that peripheral nerve blocks of the supraorbital, supratrochlear, and occipital nerves are effective in the management of migraine. This patient has a well-documented and comprehensive history of unresponsiveness to other medical therapies. However, she has demonstrated response to the performed nerve blocks, which is consistent with available literature regarding nerve blocks. According to the current data and this patients medical history, the supraorbital, occipital, and suprascapular nerve blocks of the occipital nerve on 10/3/16 and 10/20/16 were likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy.
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: Experimental
Decision: Overturned

Summary Reviewer 3

A 64-year-old female has requested reimbursement for vedolizumab infusions provided on 5/03/19 and 6/28/19. The Health Insurer has denied this request and reported that the medication at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer that the found Entyvio (vedolizumab) is an integrin antagonist specific to the gastrointestinal tract. It has a different mechanism of action than immunosuppressants and anti-tumor necrosis factor (TNF) agents, such as Remicade and Humira for ulcerative colitis. Entyvio is recommended as a first-line therapy for ulcerative colitis. Entyvio is effective for ulcerative colitis, with minimal side effects.
In this case, Entyvio is more appropriate than any alternatives. A change to an alternative could result in lack of response or complications of uncontrolled ulcerative colitis. Thus, vedolizumab infusions provided on 5/03/19 and 6/28/19 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
A 52-year-old female enrollee has requested reimbursement for BCR-ABL gene rearrangement 
quantitative polymerase chain reaction (PCR) testing, BCR-ABL fluorescent in situ hybridization 
(FISH) performed on 11/21/22. The physician reviewer found that the records provided for 
review  document  that  this  patient  presents  with  mild  leukocytosis  and  neutrophilia.  Per  Ogunleye and colleagues a diagnosis of CML is often suspected when there is leukocytosis with 
left shift and basophilia. The authors reported that, Confirmation of the diagnosis requires a 
demonstration of BCR-ABL by PCR. However, there is no report of significant basophilia or 
eosinophilia seen on peripheral blood differential. In addition, the patients records do not report 
any symptoms suggestive of CML such as night sweats, unintentional weight loss, or early satiety. 
Thus, the concern for CML in this patients clinical setting remains low. For these reasons, the 
BCR-ABL gene rearrangement quantitative PCR testing, BCR-ABL FISH performed on 11/21/22 
was not likely to be more beneficial for treatment of the patients medical condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based peer-reviewed literature support SI joint fusion in this clinical setting. Polly and colleagues concluded in their study that minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction caused by degenerative sacroiliitis or SI joint disruptions. The authors noted that pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. The International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. The criteria include: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled-out. In this case, the patient presents with chronic left hip/buttocks pain with significant functional limitation. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Clinical exam findings have documented significant tenderness at the SI joint with six positive SI joint provocative tests. There is radiographic evidence of bilateral joint arthrosis with joint space narrowing. There is no imaging evidence of lumbosacral spine neural compression pathology. Multiple bilateral SI joint injections have produced 90% pain relief. The peer-reviewed supports the requested SI joint fusion as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy in this clinical setting. 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.