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

Summary Reviewer 

A 40-year-old female enrollee has requested authorization and coverage for polysomnography, sleep monitoring of a patient six years or older in a sleep laboratory with breathing equipment. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees chronic fatigue and sleep-related complaints. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patients clinical presentation is potentially suggestive of a sleep-related breathing disorder, specifically obstructive sleep apnea. Testing would be indicated to formally evaluate for obstructive sleep apnea. The clinical presentation was not otherwise suggestive of any other form of sleep disorder that is normally assessed via polysomnography. Based on the records, an attended sleep test is not the most appropriate supply or level of service which can be safely provided to the patient. The utility and validity of home sleep testing for the diagnosis of obstructive sleep apnea has been well-documented in the literature. Clinical guidelines, technology assessments, and review articles state that portable or home polysomnography may be used as an alternative to sleep-center polysomnography for the diagnosis of obstructive sleep apnea in patients with no contraindications, such as comorbid sleep disorders or major comorbid medical disorders. In this case, a home/unattended sleep test is the appropriate initial approach to evaluation of the patients complaints. If the home study is non-diagnostic for obstructive sleep apnea, then referral for attended testing could be considered. Thus, the requested polysomnography, sleep monitoring of a patient six years or older in a sleep laboratory with breathing equipment is not medically necessary for the evaluation for the evaluation of this patient. Therefore, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 63-year-old male with a history of metastatic urothelial cancer. The patient has been treated with surgery and cisplatin and gemcitabine and most recently on clinical trial with immunotherapy. The patient is requesting reimbursement for the FoundationOne gene testing performed on 5/4/16. The Health Insurer has denied this request as investigational. In this case, the patient has already progressed after first-line therapy. Molecular analysis of urothelial cancers has shown that 60% have alterations that can be targeted by drugs already approved for use in other indications or in clinical trials. Single patient benefit has been reported. Clinical trials are recommended by National Comprehensive Cancer Network (NCCN) guidelines. Testing with FoundationOne can help identify available clinical trials or drugs approved for other indications that may be available for compassionate use. For the reasons provided, FoundationOne gene testing performed on 5/4/16 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 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 3

An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. 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 hypoglossal nerve stimulator is the most appropriate procedure and implant for the patient, considering potential benefits and harms. It is known to be effective based on scientific evidence in improving health outcomes. There are several studies that have looked at hypoglossal nerve stimulation as a way to improve upper airway stimulation and thereby treat obstructive sleep apnea. Strollo and colleagues published a study evaluating a multicenter, prospective, single-group cohort who had the device implanted. The authors concluded that aupper airway stimulation led to significant improvements in objective and subjective measurements of the severity of obstructive sleep apnea.a There is long-term data that shows a reduction in the severity of obstructive sleep, good patient compliance, a reduction in sleepiness, and improvement in quality of life. In this patientas case, he meets FDA criteria for the device. He has tried and failed CPAP treatment. His sleep study does not show evidence of central sleep apnea. In addition, he does not have complete concentric collapse of the upper airway. Finally, his apnea-hypopnea index is within the appropriate range. Thus, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 47-year-old male enrollee has requested reimbursement for the magnetic resonance imaging (MRI) of the pelvis provided on 5/19/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees prostate cancer. The physician reviewer found that repeat imaging in this clinical setting to evaluate the patient for a change in the size of the tumor focus as well as the capsule and surrounding structures is state of the art medicine. Even though the patients PSA has remained stable the patient has a history of proven malignancy even in the face of a low PSA level. Currently, prostate MRI using a 3 Tesla magnet and restriction spectrum imaging (RSI) or diffusion weighted imaging is the most sensitive way to image the prostate and the surrounding anatomy. Based on the findings on this follow-up MRI, if there had been a change in the size of the tumor or if another focus of restricted diffusion was visualized, then the patient would likely have been referred for surgery. Given this support, an MRI of the prostate was indicated and MRI has been proven to be the most reliable means for further evaluation in this clinical setting. Accordingly, the MRI of the pelvis provided on 5/19/17 was medically necessary. For the reasons discussed, the service 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 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 sufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  All told, breast tomosynthesis performed on 10/29/15 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 39-year-old male enrollee has requested authorization and coverage for Staxyn, eight tablets per month. The Health Insurer has denied this request and reported that the requested medication quantity is not medically necessary for treatment of the enrollees erectile dysfunction.  A review of the record indicates that the enrollee has been diagnosed with erectile dysfunction. Per the submitted documentation, the enrollee was prescribed Staxyn for treatment of this condition. The enrollee reported that his provider has recommended eight tablets per month, and the Health Insurer has only covered three tablets per month.  The Health Insurer indicated that the requested medication quantity is not medically necessary for treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication quantity.  At issue is whether the requested medication quantity is medically necessary for treatment of the enrollees medical condition.The Health Insurers quantity limit of the requested medication is three tablets per month. I have determined that the requested medication quantity is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis.The physician reviewer found the use of Anser IFX testing was appropriate in this patient case, to determine whether his clinical worsening was due to inadequate infliximab dosing, neutralization of the medication by antibodies, or loss of response to the medication. The use of infliximab levels and antibodies is supported by the medical literature. The studies indicate that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data (Afif et al; and Yanai and Hanauer). Change of dose or drug based on these results improves response to treatment, as measured by clinical response. The study by Hoekman and colleagues demonstrates that lower infliximab troughs are associated with elevated markers of mucosal inflammation in children. The studies cited above support the use of infliximab levels and antibody measurements in the setting of inadequate clinical response to treatment, as well as for monitoring effectiveness of dose escalation.  The alternative is to sequentially increase dose and decrease dosing frequency of infliximab, then empirically change to another medication, typically adalimumab, if lack of response persists. This clinical approach can be lengthy and can prolong a patients symptoms as well as the likelihood of an intercurrent hospital admission. Therefore, Prometheus Anser IFX diagnostic testing performed on 12/13/13 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 57-year-old male enrollee has requested authorization and coverage for the Inspire hypoglossal nerve stimulation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that this patient has severe sleep apnea with a low oxygen nadir. He has been treated with all available standard therapies including multilevel surgery, CPAP, BiPAP, and oral appliances. Evaluation with a sleep endoscopy showed he has pathology in the area which would most benefit from hypoglossal stimulation. The hypoglossal stimulation device for the treatment of obstructive sleep apnea has been proven to be safe, and effective in clinical studies (Certal, et al; Woodson, et al). This patient is a good candidate for the recommended treatment and he has exhausted all standard alternatives. Thus, the requested Inspire hypoglossal nerve stimulation therapy is likely to be more beneficial for treatment of the patients medical condition than any standard therapy. Based upon the information set forth above, I have determined 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 

The patient is a 57-year-old female with a history of chronic neck pain with right-sided radicular manifestations in the hand with intrinsic atrophy. Electromyography and nerve conduction studies have revealed C7 radiculopathy consistent with the clinical picture. The physician reviewer found that Cervical disc arthroplasty has become an acceptable and better procedure than anterior cervical discectomy and fusion for a significant patient population with cervical radiculopathy secondary to degenerative changes in the cervical spine, as in this case. Two-level total disc replacement with the U.S. Food and Drug Administration (FDA) approved Mobi-C device demonstrated excellent long-term results with lesser incidence of adjacent level disease, less pain, lesser incidence of revision surgery, and better motion compared to anterior cervical discectomy and fusion for treatment of symptomatic cervical two-level degenerative disc disease. Per the literature, this procedure is safe and effective. A hybrid construct is another option with a fusion at C7-T1 and total disc replacement at C6-7. There is sufficient support for the requested services in this clinical setting. Therefore, the requested cervical spine surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/10/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms especially in patients with heterogeneously dense tissue such as the patient in this case. Tomosynthesis allows radiologists to separate dense glandular elements form underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for surgery performed on 6/22/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees enlarged labia. A review of the record indicates that the enrollee presented to her provider on 4/27/17. The enrollee reported enlarged labia which caused her to wear panty liners daily so that the bulge would not be noticeable through her underwear. Due to pad usage, she developed chronic irritation with intermittent vaginal discharge. On 6/22/17, bilateral labia minora reduction was performed. The Health Insurer indicates that the services at issue were not medically necessary. Therefore, the Health Insurer has denied reimbursement for the services at issue.  At issue is whether the services at issue were medically necessary for treatment of the enrollees medical condition. I have determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 33-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation (64568 and 0466T). 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 sufficient support for the requested services in this clinical setting. This patient has obstructive sleep apnea, and he is status post septoplasty. Drug-induced sleep endoscopy showed no concentric collapse at velum. The patient has not been able to tolerate continuous positive airway pressure (CPAP) therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. This patient is a candidate for the Inspire device as he has failed CPAP therapy, and his body mass index and apnea-hypopnea index are within the range of pivotal FDA studies. Therefore, the requested hypoglossal nerve stimulation (64568 and 0466T) is likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 53-year-old male enrollee has requested authorization and coverage for methadone 10 mg tablets, 566 pills per 30 days. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. High-dose methadone is not recommended for chronic non-malignant pain. Clinical practice guidelines specifically identify the markedly increased risk of overdose when morphine equivalent dose exceeds 60 mg per day, as in this patients case. Due to the history of obesity, he is also at increased risk of obstructive sleep apnea, and this risk is amplified by high-dose opiates. The records do not document other approaches to pain management. Documentation of spinal cord stimulator evaluation, weight loss counseling or alternative medication was not provided. Clinical guidelines support tapering the patient and providing alternative pain management methods. Thus, methadone 10 mg tablets, 566 pills per 30 days are not medically necessary for the treatment of this patient. Therefore, the requested medication quantity is 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 


A 27-year-old male enrollee has requested authorization and coverage for venlafaxine extended release (ER) 450 mg per day. The Health Insurer has denied this request indicating that the requested dosage is not medically necessary for treatment of the enrollees generalized anxiety disorder.   The physician reviewer found that although fairly uncommon, the medical literature supports venlafaxine doses of 450 mg daily. According to the American Psychiatric Association (APA), venlafaxine exhibits linear kinetics over a dosage range of 75-450 mg/day. Further, the APA recognize that a large amount of data from randomized controlled clinical trials suggest that patients who do not respond to lower dosages often benefit from dosage increases. The presence of obsessive compulsive disorder (OCD), which typically necessitates supra-therapeutic dosing of serotonergic enhancing medication in clinical practice, further supports the requested treatment. Indeed, the APA clinical practice guideline referenced a study that demonstrated sustained clinical response for previous non-responders, without tolerability issues, of venlafaxine doses up to 450 mg daily. Considering that this patients medical records demonstrate clinical stability on the current regimen, physician recommendation, endorsement from the APA and the peer-reviewed literature base, high-dose venlafaxine therapy represents a safe, appropriate treatment consistent with good medical practice. Continuation of the therapy would be reasonably expected to maintain the patients wellness and prevent a more serious episode of illness. As such, the requested venlafaxine extended release 450 mg per day is medically necessary for treatment of the patients behavioral health condition. Based on the foregoing, the requested dosage is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
The parent of a 16-year-old female enrollee has requested reimbursement for autonomic testing 
performed on 8/19/20. 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 there is sufficient support for the services at issue in this clinical setting. This 
patient has experienced repeated episodes of near syncope, some of which are associated with 
injury. She describes that the episodes are often positional. Use of autonomic nervous system 
testing is appropriate when signs and/or symptoms of autonomic dysfunction are present, a 
definitive diagnosis cannot be made from clinical examination and routine laboratory testing 
alone, and diagnosis of the suspected autonomic disorder will lead to a change in management 
or will eliminate the need for further testing. The American Academy of Neurology Model 
Coverage Policy noted, Autonomic testing may not be able to differentiate between similar 
disorders that both cause autonomic dysfunction, but can quantify the severity of autonomic 
dysfunction,  in  other  cases  exclude  autonomic  dysfunction,  and  thereby  lead  to  specific 
recommendations for treatment. Low and colleagues noted, Modern autonomic function tests 
can  non-invasively  evaluate  the  severity  and  distribution  of  autonomic  failure.  They  have 
sufficient  sensitivity  to  detect  even  subclinical  dysautonomia.  Standard  laboratory  testing 
evaluates cardiovagal, sudomotor and adrenergic autonomic functions. Cardiovagal function is 
typically evaluated by testing heart rate response to deep breathing at a defined rate and to the 
Valsalva maneuver. Sudomotor function can be evaluated with the quantitative sudomotor axon 
reflex test and the thermoregulatory sweat test. Adrenergic function is evaluated by the blood 
pressure and heart rate responses to the Valsalva maneuver and to head-up tilt. Tests are useful 
in defining the presence of autonomic failure, their natural history, and response to treatment. 
They can also define patterns of dysautonomia that are useful in helping the clinician diagnose 
certain autonomic conditions. For example, the tests are useful in the diagnosis of the autonomic 
neuropathies and distal small fiber neuropathy. The American Academy of Neurology stresses 
the importance of being able to distinguish benign from life-threatening forms of autonomic 
nervous  system  dysfunction  by  the  use  of  autonomic  nervous  system  testing.  Therefore, 
autonomic testing performed on 8/19/20 was likely to have been more beneficial than any 
available standard therapy.