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

Summary Reviewer 


The parent of a five-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request indicating that the requested testing is not medically necessary for evaluation of the enrollees developmental delay. The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the request for genetic testing is medically necessary for evaluation of the patients medical condition. The clinical utility of CMA is well established in the peer-reviewed literature and is considered a first-line genetic test for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics (AAP), the American College of Medical Genetics (ACMG), the American College of Neurology (AAN) and the Child Neurology Society (CNS) (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). CMA technology has been shown to provide clinically actionable information. The study by Coulter and colleagues demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, and specific laboratory testing supporting the use of CMA as a clinically useful diagnostic test. Current data suggest that many clinically significant genetic changes can impact neurodevelopment without associated anatomic departures. For the reasons provided, the request for genetic testing has been established as medically necessary for evaluation of the patients medical condition. Therefore, the requested testing is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 8/19/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thin melanoma.   The physician reviewer found that the DecisionDx melanoma gene testing has been developed to assess risk of melanoma metastasis in the next five years. The National Comprehensive Cancer Network (NCCN) guidelines state that genetic tests such as the DecisionDx, should not be used outside of the clinical trial setting. Consequently, the DecisionDx melanoma assay is not considered within the standard of care. Accordingly, the DecisionDx melanoma assay provided on 8/19/15 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: Experimental
Decision: Upheld

Summary Reviewer 2


The parent of a 15-year-old male enrollee has requested reimbursement for procalcitonin testing. 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 this patient was status post incision and drainage of an abscess of the olecranon.  The provider has requested procalcitonin in addition to the complete blood count, sedimentation rate, and C-reactive protein to differentiate between inflammatory response and infection.  A review of the literature indicates that there is no specific advantage to using procalcitonin for this purpose. According to Mandell and colleagues, procalcitonin levels were higher in children with documented confirmed bacterial infection as compared with those with no suspicion of infection.  However, the authors noted that neither single nor serial procalcitonin measurements were able to predict the presence or absence of confirmed bacterial infection with enough certainty to be clinically useful as to recommend initiating or withholding antibiotics.  Therefore, the superior effectiveness of procalcitonin testing 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Per Katz and colleagues, American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Skubleny and colleagues concluded, Long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. Sheu and Rattner concluded, The long-term safety and efficacy of LINX, both alone and in comparison to current gastroesophageal reflux disease therapies, remains to be determined. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. Thus, CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is not likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 73-year-old male with a history of severe aortic stenosis. The patient was referred for transcatheter aortic valve replacement treatment.  The U.S. Food and Drug Administration has expanded the indications for transcatheter aortic valve replacement to include patients at lower risk for aortic valve surgery who meet clinical criteria for aortic valve replacement. In this case, transcatheter aortic valve replacement plus a two day hospital stay is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested reimbursement for mental health inpatient treatment services provided from 8/25/16 through 8/26/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees eating disorder. The physician reviewer found that applying the guidelines from the American Psychiatric Association (APA), the mental health inpatient treatment services provided from 8/25/16 through 8/26/16 were not medically necessary for treatment of this patients eating disorder. In records dated 8/25/16, the patients weight was 141.2 pounds and 117.7% of her ideal body weight and she was compliant with her meal plan. Thus, the patient did not require 24-hour supervision in a highly restricted setting in a mental health treatment environment to manage her anorexia and depression safely and adequately. All told, the mental health inpatient treatment services provided from 8/25/16 through 8/26/16 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

This patient is a 24-year-old female who was admitted for detoxification services on 5/23/20 after a heroin overdose. The patient has requested reimbursement for substance abuse residential treatment provided from 6/02/20 through 6/20/20. 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 per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for residential treatment services provided from 6/2/20 through 6/20/20. ASAM criteria focuses on six dimensions to determine the appropriate level of care. With regard to dimension I, acute intoxication of withdrawal potential, the patient was initially admitted to detoxification services and managed for withdrawal. She had Clinical Institute Withdrawal Assessment (CIWA) scores ranging from 7 to 15 after moving to the residential treatment center. Thus, her withdrawal needs could have been managed in Level 3.5 setting. In terms of dimension II, biomedical conditions, this patient did not have any identified medical problems. With regard to dimension III, emotional, behavioral, or cognitive conditions, the patient has been diagnosed with bipolar disorder. She was noted to have hallucinations and delusional thinking while in the residential treatment center that affected her insight into her condition. She also was noted to be impulsive and needed frequent boundary setting. Although this patientas mental status permitted participation in the residential treatment program, the records noted significant functional deficits that were sufficiently severe that she was not likely to maintain mental stability or abstinence if treatment was not provided in a non-residential setting. In terms of dimension IV, readiness to change, the patient was noted to be in the contemplative stage of change. She had experienced persistent psychotic symptoms and significant overdosage as serious consequences. She was noted to blame relationships and others for her ongoing usage. Thus, despite experiencing serious consequences, the patient had marked difficulty in understanding the relationship between substance use and her impaired coping skills and level of functioning, often blaming others for her addiction problems. With regard to dimension V, relapse, continued use, or continued problem potential, the patient did not recognize relapse triggers and lacked insight into benefits of continuing care. In terms of dimension VI, recovery environment, the patientas social network included regular users of drugs such that recovery goals are assessed as unachievable at a less intensive level of care. In sum, the submitted records support the medical necessity of the services at issue. Therefore, substance abuse residential treatment provided from 6/02/20 through 6/20/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 46-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier testing performed on 9/6/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees thyroid nodule.The physician reviewer found the American Thyroid Associations guidelines state that for follicular neoplasm nodules, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. In this case, the cytopathology of the 3.4 cm thyroid nodule was consistent with a follicular neoplasm. The risk of malignancy is 15-30% in follicular neoplasm nodules (Cibas, et al; Haugen, et al). The result of the gene expression classifier was benign, which may prevent unnecessary surgery. In addition, there are multiple peer-reviewed scientific articles supporting the benefit of genetic testing in thyroid nodules (Haugen, et al; Alexander, et al). Therefore, the Afirma Gene Expression Classifier testing performed on 9/6/16 was likely to be more beneficial for the evaluation of the patients medical condition than other 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: Upheld

Summary Reviewer 3


A 49-year-old male enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 5/29/14. 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 the medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer, but not for those with stage II disease.  The reasons for this conclusion are complex. Stage II patients do well after surgery alone so that the magnitude of the survival benefit conferred by adjuvant chemotherapy is small; and, randomized clinical trials to date have had too few stage II patients to discern a statistically significant advantage.  Therefore, subset analyses to identify those patients with prognostic features that may predict for chemotherapy benefit have been analyzed. For example, oncologists consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers.  The Oncotype DX test uses a reverse transcriptase-polymerase chain reaction assay for 12 genes in an algorithm that can be used to predict recurrence. The test was validated independently as being an excellent prognostic indicator. It remains an open question whether adjuvant chemotherapy can obviate recurrence risk. Nevertheless, the medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients and incorporated with other tests such as standard pathology and microsatellite instability testing.  Thus, Oncotype DX Colon Cancer Assay performed on 5/29/14 was likely to have been of greater benefit 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 33-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees small bowel Crohns disease. The physician reviewer found in this case, Anser IFX was ordered to determine infliximab level and whether antibodies to infliximab were present. The use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear infliximab levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing (Vande Casteele, et al). A systematic review reported that future prospective controlled studies are needed, especially considering that anti-tumor necrosis factor (TNF) levels are influenced by several variables that can fluctuate over time and among individuals (Yarur, et al). For these reasons, the Anser IFX testing performed on 2/18/16 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 29-year-old female enrollee has requested authorization and coverage for lumbar spine magnetic resonance imaging. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has a progressive problem related to her lumbar spine. While she has intact reflexes and no red flags, she has completed a six-week course of physical therapy, and still has symptoms. Because her symptoms have worsened since her MRI in 2010 and she has completed a supervised six-week course of physical therapy in June and July 2019 without relief, MRI of the lumbar spine is medically appropriate. Therefore, the requested lumbar spine MRI is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is 61-year-old male who presented for a neurology consultation on 10/21/16 for chief complaints of snoring and fatigue. The patient endorsed snoring, non-restorative sleep and daytime sleepiness. He endorsed a past history of (nocturnal) teeth grinding.  The patient was reportedly previously diagnosed with obstructive sleep apnea (OSA) but was unable to tolerate continuous positive airway pressure therapy (CPAP).  The patient reported a history of seizures, which were characterized as lapses.  He was on Keppra extended release for this condition.  Physical examination showed the patient to be 69 inches tall and weighed 181 pounds.  Physical examination was said to show a beefy tongue and narrow inlets in the nose.  The provider listed a primary diagnosis of sleep apnea.  The patient was referred for split night polysomnography.  On 11/1/16, the patient reportedly underwent a split night study where the patients apnea hypopnea index was 1.2 events per hour.  The recording technologist initiated CPAP during the study.  The final report stated that CPAP was applied but that the patient was unable to tolerate CPAP. The patient has requested reimbursement for in-laboratory sleep study performed on 11/1/16. The Health Insurer denied reimbursement and reported that the services at issue were not medically necessary for the evaluation of this patients sleep disorder. There is a lack of support in the medical literature for the medical necessity of the services at issue in this clinical setting. In this case, the patient presented with a clinical presentation that was suggestive of a sleep related breathing disorder.  He was noted to have had a prior diagnosis of OSA.  He endorsed snoring and non-restorative sleep.  He also had a history of gastroesophageal reflux disease and an enlarged tongue.  These are all potential signs of OSA (Jordan, et al; Epstein, et al 2016). Given the prior diagnosis of OSA and signs and reported symptoms, sleep testing would have been clinically appropriate (Kapur, et al). In this patient, with a reasonably high pre-test probability of OSA particularly given his prior diagnosis, testing could have been performed in the ambulatory or home setting.  As noted by Jordan and colleagues, there has been a shift from the attended to the unattended setting for such testing. A recent study by Donovan and colleagues also reported the same shift. While testing was indicated in this patients case, performance of attended sleep testing exceeded this patients clinical and diagnostic needs.  In this regard, in-laboratory sleep study performed on 11/1/16 was not medically necessary. Therefore, for the reasons stated above, the services at issue were not medically necessary for the evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of a 14-year-old male enrollee has requested reimbursement for wilderness treatment therapy provided from 7/16/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is some support for the services at issue in this setting. Behrens and colleagues noted that in a longitudinal outcome study it was shown that youth in the study experienced significant decreases in suicidal ideation, anxiety, depression, substance abuse, social conflict, sleep disruption, violence, as well as an overall reduction in externalizing behaviors such as impulsivity, defiance, and hostility. Furthermore, these youth demonstrated improvements in work and academic functioning during the follow-up portion of the study. DeMille and colleagues noted that, youth participants who attended an outdoor behavioral healthcare treatment program were, as reported by their parents, functioning significantly better than the Treatment as Usual (TAU) group one year following the program as measured by the Youth Outcome Questionnaire 2.01. Youth who remained in their communities were still at acute levels of psychosocial dysfunction during the same time span. Despite some differences between the means of the treatment and TAU groups across time between gender and groups, a regression analysis revealed age and gender not to be significant predictors of improvement. The only significant predictor was participation in the treatment group. In this patients case, wilderness therapy was in accordance with generally accepted standards of medical practice. Therefore, wilderness treatment therapy provided from 7/16/18 through 8/30/18 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 58-year-old female enrollee has requested authorization and coverage for the LINX device.  The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that one of the main adverse events related to the placement of a LINX device is dysphagia. When severe, these symptoms could lead to the need to remove the device. This patient has a hypertensive LES and EGJ outflow obstruction along with a history of a food impaction. Therefore, this patient is at markedly increased risk for having dysphagia or future events of food bolus obstruction if the LINX is placed. Additionally, the patients underlying motility disorder is likely contributing to her symptoms as she experiences frequent symptoms 24-hours per day, but only has a borderline positive study for acid reflux. All told, the requested LINX device 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 procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.