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

Summary Reviewer 1

The patient is a 20-year-old male with a diagnosis of overactive bladder, insomnia, and anxiety. The patients associated symptoms include urinary frequency and nocturia.  Prior treatment has included overactive bladder anticholinergics and Myrbetriq. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. As noted in the medical literature, treatment in this clinical setting should including behavioral therapies with bladder training, bladder control strategies, pelvic floor muscle training, and fluid management as first-line therapy. Behavioral therapies may be combined with pharmacologic management. Overall, the guidelines suggest that PTNS is not recommended as a first- or second-line therapy and PTNS has not been proven to be superior to other alternatives. Thus, the PTNS provided on 10/16/17 was 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 service at issue was 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 3


A 22-year-old female enrollee has requested authorization and coverage for spine nerve treatment, procedure codes 64634 and 64633. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that spine nerve treatment, procedure codes 64634 and 64633 are likely to be more beneficial for treatment of the enrollees medical condition. The majority of peer-reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. Tzaan and colleagues performed a retrospective study to assess the value of percutaneous radiofrequency facet rhizotomy. The authors concluded that the procedure is simple and safe in patients with disabling spinal pain that fail to respond to conservative treatment. In this case, the physical exam and MRI is significant for multi-level spondylosis and facet mediated pain. Per the provider notes the patient has had significant relief with prior radiofrequency of the thoracic facet. Therefore, the requested services are 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: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has been assessed with cardiovascular disease. The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting.  The patient has been diagnosed with hyperlipidemia with no documented clinical cardiovascular events or significant carotid stenosis. The records do document intolerance to one statin medication (simvastatin). Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL-cholesterol (Sabatine, et al; Robinson, et al). The records submitted do not support the criteria as outlined by the literature.  Studies are lacking to support the use of PCSK9 inhibitors in other patient populations such as this patient. In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting (Stone, et al). All told, Repatha is not medically necessary for the treatment of this patient. Therefore, based on the above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 43-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/8/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that this patient is a 43-year-old female who had a bilateral screening mammogram with tomosynthesis on 8/8/16. There were scattered fibroglandular elements in both breasts. The impression was negative. The patient requested reimbursement for the breast tomosynthesis performed on 8/8/16. The Health Insurer denied the request for reimbursement. Per the Health Insurer, the service at issue was investigational for the evaluation of this patient. The medical literature supports breast tomosynthesis 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. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/8/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 49-year-old male enrollee has requested authorization and coverage for Simponi injections 50 mg/0.5 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees rheumatoid arthritis. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Simponi has been recommended along with the other anti-tumor necrosis factor agents by the American College of Rheumatology for the treatment of rheumatoid arthritis. Based on a double-blind, randomized, placebo-controlled study by Bingham and colleagues, golimumab-treated patients had significantly greater improvements in the signs and symptoms of rheumatoid arthritis through week 24 when compared with placebo, with some patients experiencing a rapid onset of response as early as two weeks after initiating golimumab therapy, and efficacy was maintained through one year.  Current peer-reviewed medical studies have established the safety and efficacy of Simponi for the management of rheumatoid arthritis symptoms. As such, Simponi injections 50 mg/0.5 mL is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 52-year-old male who has been diagnosed with spondylosis without myelopathy or radiculopathy, lumbar region; other intervertebral disc degeneration, lumbar; and low back pain.  The patient has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that according to the U.S. Food and Drug Administration (FDA) Indications for Use, The Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care, and is also accompanied by features consistent with Type 1 or Type 2 Modic changes on an MRI such as inflammation, edema, vertebral endplate changes, disruption and fissuring of the endplate, vascularized fibrous tissues within the adjacent marrow, hypointensive signals (Type 1 Modic change), and changes to the vertebral body marrow including replacement of normal bone marrow by fat, and hyperintensive signals (Type 2 Modic change). There is a lack of support for the requested services in this patients case. FDA criteria would only have been plausibly met if the patient had chronic low back pain generators that had been clearly delineated as being linked to the spinal vertebral body(s) in origin. In this case, there were/are multiple plausible pathologic sources of significant pain generation. These included the documented tender trigger points (clinically associated with a peri-spinal soft tissue origin) and the tender facet joints (the portion of the spinal vertebrae dorsal to the vertebral bodies themselves). The non-radiating midline back pain, the noted pain-aggravating and pain-relieving factors, along with the diminished and painful spinal motion (in all directions) and intact neurologic examination were/are all non-specific to any pathologic entities. Overall, documentation is lacking regarding reasonably detailed and/or evidenced findings supportive of the spinal vertebral bodies as being the overwhelming primary generators of the patients chronic persistent pain. The records do not support actual formal surgical ablation of pre-designated basivertebral nerves as being medically necessary and/or reasonable at this time. Therefore, the requested Intracept procedure is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old female enrollee has requested authorization and coverage for 22870 and 22869 (insertion of stabilization device without compression). 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 the interspinous process decompression offers an intermediate step in the continuum of care for patients with neurogenic intermittent claudication associated with lumbar spinal stenosis. There are many interspinous devices on the market; however, the devices lack high-quality research to demonstrate safety that is better than the current standard of care, simple decompression. Coupling surgical decompression techniques with the use of interspinous devices has added confusion to the contribution of interspinous devices in pain/symptom relief. In this case, the patient is being treated for chronic low back pain with radiation to bilateral lower extremities. There is insufficient evidence to support the use of interspinous devices for the treatment of spinal stenosis with neurogenic claudication versus decompression alone. All told, the requested CPT codes 22869 and 22870 (insertion of stabilization device without decompression) are not likely to be more beneficial for treatment of the patients medical condition than any standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


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 the level of procalcitonin in the blood rises in response to a pro-inflammatory stimulus, especially of bacterial origin.  It does not respond significantly to viral or non-infectious inflammations.  Measurement of procalcitonin can be used as a marker of severe sepsis, with a level of sensitivity of 85% and specificity of 91% in differentiating systemic inflammatory response syndrome from sepsis.  However, there is a lack of support for the services at issue in this clinical setting.  In this patients case, there was a readily accessible infection at the extensor surface of the elbow accessible to palpation and with white blood cell count monitoring and C-reactive protein monitoring. The presence of bacterial infection and the need for incision and drainage is a decision which may be made without obtaining this additional biometric.  Thus, procalcitonin level was not likely to have been of greater benefit than other modalities.  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 2


A 64-year-old female enrollee has requested reimbursement for the Decision DX Melanoma assay performed on 6/16/15. 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presents with Stage I melanoma, with no adverse prognostic features. In this clinical setting, adjuvant therapy is only indicated for patients with node positive disease. Further studies are needed to assess Decision DX Melanoma assay and how the results will be incorporated into staging and ultimately treatment. The standard therapy for a Stage I melanoma is wide excision. In addition, the American Joint Committee on Cancer (AJCC) does not recommend Decision DX Melanoma assay in this clinical setting. 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 2

A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/17/15 and 1/12/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration (FDA) in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) supports the utility of tomosynthesis, especially in patients with extremely or heterogeneously dense tissue such as the patient under this review. This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers. Thus, on the screening exam of 12/17/15, the addition of tomosynthesis to the usual two dimensional views was likely of more benefit to the patient than had the exam been done with two dimensional technique alone. However, the follow-up left diagnostic mammogram on 1/12/16 was for the purpose of characterization of the detected left breast calcifications. These calcifications required magnification spot views in 90 degree orthogonal planes and not a repeat tomosynthesis. It is unlikely that such a repeat tomosynthesis view added anything in addition to the information available on the magnification views. Accordingly, the breast tomosynthesis provided on 12/17/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy while the study performed on and 1/12/16 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, a portion of 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 partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 49-year-old transgender female enrollee has requested reimbursement for facial feminization procedure provided on 3/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has been diagnosed with gender dysphoria, and the records noted social anxiety and depression. The records documented distress related to masculine facial features as well as distress regarding being perceived as male by others. For patients with gender dysphoria, facial feminization surgery is medically necessary in the setting of clinically significant distress or functional impairment. World Professional Association for Transgender Health (WPATH) criteria for surgery state that surgical procedures for patients with gender dysphoria may include augmentation mammoplasty, genital surgery and other interventions, such as facial feminization surgery, liposuction, lipofilling and thyroid cartilage reduction. Thus, the current medical evidence supports the services at issue in this clinical setting. In sum, facial feminization procedure provided on 3/26/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested reimbursement for inpatient mental health treatment from 2/08/16 through 2/11/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general, community intervention settings optimize treatment gains.  However, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness. In this case, the patient was suffering from an extraordinarily severe mental illness. The treating psychiatrist determined that the patients symptom complex could not be managed at a lower level of care.  She had a prominent illness burden and abysmal insight.  She had limited social support.  She required long-term specialty care and there was reasonable concern that discharge to home would have terminated rather than interrupted the episode of care.  The treatment was safe, appropriate and reasonably expected to prevent a worsening of illness.  All told, inpatient mental health treatment from 2/08/16 through 2/11/16 was medically indicated for the treatment of this patient.  Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 61-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) scan. The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees lung cancer. The physician reviewer found that The National Comprehensive Cancer Network (NCCN) has established guidelines for the initial work-up and then treatment and surveillance for small cell lung carcinoma.  The initial work-up will often include, among other modalities, a PET/CT scan. When there is evidence of a new nodule or mass, the NCCN recommends that the patient be re-evaluated as if the new mass could be a new primary tumor. This initial evaluation would likely include a PET/CT scan. In this patients case, PET scan is likely to alter management.  If the PET scan were to show metabolic activity, it is likely that the patient will undergo another round of chemotherapy. A strikingly high standardized uptake value (SUV) will indicate tumor. All told, the requested PET scan is likely to be superior over other methods of evaluating this patient. Based upon the information set forth above, the requested services are 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 


A 29-year-old female enrollee has requested reimbursement for the inpatient admission services provided from 4/27/17 through 4/28/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees lymphadenopathy. The physician reviewer found that this patients records did not document emergency or life threatening signs or symptoms that necessitated a hospital admission. The patients history, physical examination, laboratory or radiographic evaluation did not indicate the patient was in imminent danger, acutely ill, or medically unstable. For this reason, the work-up could have been performed on an outpatient basis. Accordingly, the inpatient admission services provided from 4/27/17 through 4/28/17 were not medically necessary for treatment of the patients medical condition. 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 


A 43-year-old transgender female enrollee has requested authorization and coverage for electrolysis epilation, each 30 minutes. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found the requested services are within accepted standard of practice and clinically appropriate for treatment of this patients gender dysphoria. In this case, the patient is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. She has transitioned into living as a female since she began hormone therapy in 2013. The requested epilation hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested treatment may improve emotional function in this patient. It would create a more feminine genital or extremity appearance. The medical literature support the services at issue for treatment of gender dysphoria. Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.