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

Summary Reviewer 1

A 61-year-old female enrollee has requested authorization and coverage for breath hydrogen/methane test (91065). The Health Insurer has denied this request and reported that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this patients. In the setting of blood in the stool of a 61-year-old patient, a colonoscopy is typically warranted. The submitted records do not document that this study was performed. The clinical notes do not support that breath testing for small intestinal bacterial overgrowth is likely to be more beneficial for the evaluation of this patient than colonoscopy. If the patient has small intestinal bacterial overgrowth, options in lieu of breath testing could include empiric trials of Xifaxan and/or probiotics. Therefore, breath hydrogen/methane test (91065) is not likely to be superior over other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 10-year-old female enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees short stature.  A review of the record indicates the enrollee has a history of short stature. Per the provider, the enrollees height dramatically improved at the time she started human growth hormone in November 2014. Since starting growth hormone and catching up her growth, the enrollees development and confidence have improved. Prior to treatment, the enrollees growth chart showed she was in the 1.2 percentile which is 2.25 standard deviations below average. The records note the enrollee has a mid-parental height (MPH) of 5 feet 5.5 inches, and was more than two standard deviations below her mid-parental height.  The Health Insurer indicates the requested medication is not medically necessary for treatment of the enrollees medical condition.  At issue in this case is whether the requested medication is medically necessary for treatment of the enrollees medical condition. I have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 36-year-old male with a history of heartburn and postprandial symptoms. The patients symptoms have reportedly been incompletely improved with proton pump inhibitor (PPI) therapy, or with ranitidine in combination with sucralfate. Per charting dated 1/27/16, an upper endoscopy demonstrated irregular Z-line, small hiatal hernia and chronic carditis. An esophageal manometry demonstrated normal motility with low lower esophageal sphincter (LES) pressures and minimal hiatal hernia. A 24-hour pH impedance off of PPI demonstrated a DeMeester score of 10.9 with symptom association probability (SAP) of 76%. The provider notes that the patient does not seem to have nocturnal reflux. On 3/7/16, ambulatory pH monitoring off acid blockers showed a composite DeMeester score of 30.1 with good symptom correlation with heartburn. An esophagogastroduodencoscopy (EGD) on 3/7/16 showed a histologically unremarkable upper gastrointestinal (GI) tract to the duodenum. The patient has requested authorization and coverage for transoral incisionless fundoplication (TIF) with EsophyX device. The Health Insurer has denied this request as investigational.  The request for TIF with EsophyX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patients acid reflux has been documented by pH testing, but the studies were performed off of acid suppression therapy. There is a lack of documentation provided to support that the patients reflux is refractory to optimally-dosed conventional acid suppression, nor that he has endoscopically-confirmed significant esophageal injury secondary to gastroesophageal reflux disease (GERD). Therefore, the request for TIF with EsophyX device procedure 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/04/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network (NCCN) guidelines states that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing was not likely to have altered treatment and surveillance recommendations. In sum, the superior effectiveness of gene expression profiling performed on 5/04/17 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: Overturned

Summary Reviewer 3


A 33-year-old female enrollee has requested reimbursement for gene testing (BRAF mutation analysis) provided on 11/19/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees papillary thyroid carcinoma. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Papillary thyroid cancer is a frequent histologic subtype of thyroid cancer. The genetics can be complex and the BRAF mutations are frequent. This is notable since the presence of the mutation provides significant prognostic information (Fraser, et al; Lee, et al; Kim, et al). The medical literature supports a role for BRAF mutational testing in this clinical setting. Accordingly, the gene testing (BRAF mutation analysis) provided on 11/19/15 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 1

A 62-year-old male enrollee has requested reimbursement for homocysteine, Factor V Leiden and methylenetetrahydrofolate reductase (MTHFR) testing provided on 4/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees right lower extremity deep vein thrombosis (DVT). The physician reviewer found the DVT and pulmonary embolism may be caused by hereditary thrombophilias. Information regarding the increased risk is important especially in situations of prolonged immobility such as surgery, long car trips, or long airplane flights. These complications may be prevented by appropriate interventions and the avoidance of estrogens, which are prothrombic. The Prothrombin (F2) G20210A mutation increases risk of DVT about three-fold, but nearly 20-fold in compound heterozygous patients with Factor V Leiden (Emmerich, et al; Koeleman, et al). Similarly, patients with hyperhomocysteinemia and Factor V Leiden are at greatly increased risk for DVT (Ridker, et al). The most common genetic cause for hyperhomocysteinemia is the thermolabile variant of the MTHFR enzyme. This is due to homozygosity for the TT genotype at codon 677 (Kluijtmans, et al). Given that appropriate interventions should be taken if mutations are identified, the homocysteine testing, Factor V Leiden and MTHFR provided on 4/28/16 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: Upheld

Summary Reviewer 3 
  A 44-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/28/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees melanoma. The physician 
reviewer found that the pathology from the left upper back shows a T1a cutaneous melanoma. 
Gene  expression  profile  (GEP) testing,  such  as  DecisionDx-Melanoma testing,  can assist  in 
differentiating a precancerous lesion from melanoma and also help risk stratify for cancer 
recurrence,  although  it  is  unclear  if  this  performs  better  than  standard  methods  such  as 
histopathologic features and sentinel lymph node biopsy. Further, National Comprehensive 
Cancer Network guidelines do not recommend routine laboratory testing or imaging for stage IA 
disease, after full wide excision of the melanoma, so surveillance would not be altered in this 
case. Therefore, DecisionDx-Melanoma testing performed on 7/28/21 was not likely to have been 
more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 31-year-old female enrollee has requested authorization and coverage for exome sequence analysis (gene panel testing). The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this patients case.  The records do not demonstrate that a specific genetic condition is suspected by the requesting provider.  In the absence of a proposed diagnosis, there is insufficient evidence that this testing will change management or improve health for this patient.   In addition, given the early state of this technology, the implications of many genetic mutations are not currently known.  For these reasons, the requested services are not likely to be more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 61-year-old male enrollee has requested reimbursement for physical therapy services performed from 8/27/15 through 12/5/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of low back pain, knee pain and bilateral arm numbness. The physician reviewer found that there is a lack of medical studies to show the efficacy of the services at issue in this clinical setting. A review by Yuan and colleagues provided some evidence to show that acupuncture, acupressure, and cupping could be efficacious but they could not draw definite conclusions. Their study consisted of over seventy five randomized controlled trials with over 11,000 patients evaluated. Another study also showed cupping could be promising for pain control and improvement of quality of life, and minimizes the potential risks of treatment (Huang, et al). However, further studies were recommended in order to analyze the potential role of cupping therapy in the treatment of low back pain. In a study by Arguisuelas and colleagues, they could not determine if myofascial treatment showed any clinical significance. In addition, this patient has had extensive treatment of acupuncture with ancillary therapies but the records do not indicate a clear improvement of functional benefit. Although the services at issue show some promise as treatment modalities for pain, more studies are recommended. As such, the physical therapy services provided between 8/27/15 and 12/5/15 were not likely to have been more effective than the available standard treatment options for this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 70-year-old female enrollee has requested reimbursement for an intermittent limb compression device provided from 10/13/16 through 10/28/16. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees right knee pain. The physician reviewer found that the patient underwent arthroscopic surgery for osteoarthritis of the right knee including degenerative meniscal tears and chondromalacia on 10/13/16. There is no prior history of thromboembolism. The recent medical literature suggests that the incidence of symptomatic venous thromboembolism after arthroscopic knee surgery is very low and therefore the guidelines do not recommend intermittent pneumatic compression or pharmacotherapy postoperatively (Mauck, et al). The guidelines from the American College of Chest Physicians and American Academy of Orthopedic Surgeons agree that routine prophylaxis to prevent symptomatic venous thromboembolism is not needed for patients undergoing outpatient knee arthroscopy (Falck-Ytter, et al). For these reasons, the intermittent pneumatic compression provided from 10/13/16 through 10/28/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the device at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 63-year-old female enrollee has requested reimbursement for the Prolia injection performed on 11/21/14. The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found the Prolia injection performed on 11/21/14 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is data to support use of Prolia in this clinical setting. Denosumab has been associated with a reduction in the risk of vertebral, non-vertebral, and hip fractures in women with osteoporosis (Cummings, et al). In this case, the patient tried a bisphosphonate and was intolerant of this according to the records provided. In addition, she has osteoporosis with a documented T-score of -2.6. All told, the services at issue were 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 31-year-old female who was transported from Sharp Memorial Hospital to Sharp Mesa Vista Hospital on 4/28/19. She had arrived at Sharp Memorial Hospital for attempted overdose. The physician reviewer found that this patient presented with suicidal ideation and was diagnosed with psychosis. The reason for transport is listed as psychiatric monitoring. Transportation of mental health patients between facilities by emergency medical services personnel poses a unique risk to both patients and their providers. Standard of care is to transport all such patients by basic ambulance. Special handling with the use of restraints could be required during transport to prevent self-injury by the patient as well as injury to transport staff. Emergency medical technicians (EMTs) possess the requisite training to apply restraints. Therefore, EMT attendance is required for such transports. There is sufficient support for the services at issue in this clinical setting. Therefore, non-emergent ambulance services provided on 4/28/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for inpatient services provided from 6/21/17 through 6/26/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees non-ST-elevation myocardial infarction. The physician reviewer found that this patient presented with a non-ST segment myocardial infarction on 6/19/17, and she was treated with medication including intravenous heparin. In this setting, it is standard of practice to treat with intravenous heparin for 48 to 72 hours. Since the patient was on intravenous heparin for at least part of the day on 6/21/17, she could not have been safely discharged on that day.  However, since she remained clinically stable without recurrent chest discomfort or other evidence of ongoing ischemia on 6/22/17, about 24 hours after heparin was discontinued, it would have been medically safe to discharge the patient on this date, to return for coronary bypass surgery once dental abscess and nickel allergy had been sufficiently evaluated and treated. The records do not support the medical necessity for continued inpatient care beyond 6/22/17. All told, inpatient services provided from 6/21/17 through 6/22/17 were medically necessary for the treatment of this patient, 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 2

A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that polymerase chain reaction testing is likely to have been more beneficial than any available standard therapy in this case. For a patient who presents with symptoms of abnormal vaginal discharge, an examination of the vaginal discharge, including microscopic evidence of infection, can lead to a definitive diagnosis. In the case, where microscopy is not available, commercial diagnostic testing methods, including polymerase chain reaction, are used for confirming the clinical suspicion of bacterial vaginosis, vaginal candidiasis, or trichomonas vaginitis. Furthermore, polymerase chain reaction testing can be utilized for detecting both gonorrhea and chlamydia. Microscopy is no longer widely available in clinic settings, and practices are now relying on this testing to diagnose and treat vaginitis. Current studies reported sensitivities and specificities of over 96 percent for the detection of Neisseria gonorrhoeae and Chlamydia trachomatis. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 19-year-old male enrollee has requested authorization and coverage for lumbar disc 
arthroplasty and two inpatient days. 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 lumbar disc arthroplasty (LDA) remains a 
controversial surgical strategy for the treatment of low back pain related to isolated 
degenerative disc disease, mostly based on its comparison to what is perceived as the gold 
standard surgical procedure, lumbar spinal fusion. When attempting to discern the efficacy and 
safety of lumbar disc arthroplasty, it is important to note that there are meaningful data both 
favorable and unfavorable regarding the technique, in particular when comparing it to lumbar 
fusion surgery. Guntin and colleagues systematically reviewed 57 seminal publications and 
noted that only 39 of them reported favorable results for lumbar disc arthroplasty in this 
context. The main thrust of their review, however, was to analyze how conflicts of interest 
influence the outcomes of studies in the lumbar disc arthroplasty literature. They noted that 
manuscripts where conflicts of interest were present were significantly more likely to report 
favorable outcomes of lumbar disc arthroplasty versus non-conflicted studies.  A number of 
other systematic reviews and meta-analyses have failed to demonstrate superiority of lumbar 
disc arthroplasty to fusion but found it equivalent. The standard therapies for the treatment of 
the patient include the following: medications, physical therapy (including traction), spinal 
injections, bracing, alternative therapies (i.e. acupuncture) and lifestyle modifications. The gold 
standard surgical treatment is a fusion surgery. This patient has already attempted and failed 
meaningful non-surgical strategies. On the basis that the abundance of accumulating evidence 
supports at best equivalence of lumbar disc arthroplasty to fusion surgery in this setting, the 
superior efficacy of the requested services has not been demonstrated. The requested services 
are not likely to be more beneficial than other surgical strategies, like decompression and 
fusion. Therefore, the requested lumbar disc arthroplasty and two inpatient days are not likely 
to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 52-year-old female enrollee has requested reimbursement for bilateral reduction mastopexies provided on 3/21/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bilateral macromastia with ptosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records do not document that the patient had typical signs and symptoms associated with functional impairment related to macromastia. There was no medical description of pain, shoulder grooving, chronic rashes or other signs and symptoms to support that the planned procedure was reconstructive surgery. Thus, bilateral reduction mastopexies provided on 3/21/17 was not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.