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

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan performed on 2/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees rigidity, lack of response to Sinemet trial, with suspected Parkinsons disease. The physician reviewer found that in the medical literature, Suwijn and colleagues reported that Parkinsons disease (PD) is wrongly diagnosed in 6 to 25% of cases. To improve the accuracy of the clinical diagnosis, it is necessary to have a reliable and practical reference standard. Dopamine transporter single-photon emission computed tomography (DAT SPECT) imaging might have the potential (high diagnostic accuracy and practical to use) to act as reference standard in detecting nigrostriatal cell loss in patients with (early stage) parkinsonism. Kagi and colleagues found that the use of DAT SPECT can prove or exclude with high sensitivity nigrostriatal dysfunction in those cases and facilitates early and accurate diagnosis. Thus, the literature does support the use of DAT SPECT for the diagnosis of Parkinsons disease. Given this support, the SPECT scan performed on 2/17/15 was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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 

A 56-year-old female enrollee has requested authorization and coverage for Repatha SureClick (evolocumab subcutaneous solution auto-injector 140 mg/mL). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hyperlipidemia. The physician reviewer found that in this case, there is no documented heart disease and mildly elevated LDL level. The patient has been intolerant of two statin medications and Zetia. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor sufficiently studied only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. This patient does not fit any of those criteria. PCSK9 inhibitors have not been sufficiently studied in other patient populations, such as this patient with no documented cardiovascular disease and relatively mildly elevated lipid levels after lifestyle changes.   Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Thus, Repatha SureClick (evolocumab subcutaneous solution auto-injector 140 mg/mL) is not medically necessary for the treatment of this patient. Therefore, 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: Upheld

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/27/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the standard protocol for an intermediate thickness tumor such as in this case does not include a work-up with molecular genetic testing. Although DecisionDx-Melanoma testing has shown results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. Currently the standard of care includes wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There are no clinical studies at this time that show that the results of the molecular testing will make a difference in the treatment or morbidity or mortality of the patient. For the reasons provided, the DecisionDx-Melanoma testing performed on 10/27/16 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: Upheld

Summary Reviewer 


A 49-year-old female enrollee has requested reimbursement for DecisionDX-Melanoma assay test performed on 6/30/14. The Health Insurer has denied this request indicating that the test at issue was not medically necessary for evaluation of the enrollees cutaneous melanoma. The physician reviewer found the prognosis of cutaneous melanoma has classically been determined by the staging system as documented by Balch and colleagues. Mitotic index has also been thought to add a bit more to the prognostics. By these determinations, this patient has an excellent prognosis. DecisionDX is a study of 31 genes in the melanoma cells. It then classifies that melanoma as either high or low risk for recurrence (Dillion et al). The National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles, but only in the context of a clinical trial. Currently, medical studies are not clear as to how DecisionDX data compares to the 10 year data of the Balch determinations and whether it is useful in clinical practice for patients with a good prognosis, as is true in this patients case. In sum, this assay was not medically necessary in evaluating this patients likelihood of metastasis in cutaneous melanoma. Based on the information above, the test at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 73-year-old female who presented to her provider on 7/19/22. The records noted 
statin intolerance, coronary artery disease, and an abnormal electron beam computed tomography 
(EBCT) result. The patient has requested authorization and coverage for Repatha Sureclick 
solution auto-injector 140 mg/mL. The Health Insurer has denied this request and reported that the 
requested medication is not medically necessary for the treatment of this patient. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the requested medication. In this case, the records 
document that the patient has coronary artery disease, has been unable to tolerate multiple statins, 
has a high LDL level, and an abnormal EBCT result. In addition, according to Nissen and 
colleagues, this medication has been successfully used in statin intolerant patients. In this clinical 
setting, current medical literature supports the use of the requested medication. Therefore, Repatha 
Sureclick solution auto-injector 140 mg/mL is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD), dysphagia and hiatal hernia. The physician reviewer found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures in the treatment of patients with GERD. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review found that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). One peer-reviewed study reported that there are 11 cases of endoscopically-confirmed LINX erosion through the esophagus in the FDA Adverse Events database (Bielefeldt). Additionally, LINX has been associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). The American College of Gastroenterology guidelines for the management of GERD also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX procedure is not supported as medically necessary for the treatment of the patients medical condition. Based on the foregoing discussion, the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health partial hospitalization program (PHP) services from 2/20/16 and forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. According to the records the patient was no longer a threat to himself as of 2/20/16 and he was not a danger to others.  There was no evidence of psychosis or mania.  He was able to perform his active daily living (ADL) and he was cognitively intact. He had made progress and was able to exert control over his behavior to an extent that a lower level of care would have been appropriate and indicated. The patients family was actively engaged and supportive.  He did not have coexistent medical or acute substance abuse issues that would have interfered with treatment at a lower level of care.  The patients symptoms and behavior were no longer of an acuity requiring PHP level of care.  For these reasons, the services at issue were not and are not medically necessary in the treatment of the patients medical condition.  The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 2


A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15.  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 current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis has been demonstrated to be of particular benefit in women with extremely dense and heterogeneously dense tissue.  The tomographic nature of this technique often allows radiologists to separate dense underlying glandular elements from architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of more benefit to this patient than if she had 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/08/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her examination been done with two-dimensional imaging alone.  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: Experimental
Decision: Upheld

Summary Reviewer 2


A 61-year-old female enrollee has requested reimbursement for the in-office surgical injections performed on 8/4/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees lumbar spondylosis with arthropathy.   The physician reviewer found that the available records document that this patient has mild facet arthropathy as demonstrated on magnetic resonance imaging (MRI) as well as having discogenic radiculopathy. However, the medial branch blocks performed on 8/4/15 are not indicated in the presence of another clear cause of the patients low back and radicular pain. Further, the use of repeated diagnostic blocks absent a plan for radiofrequency neurolysis is not consistent with clinical practice guidelines. Thus, the in-office surgical injections performed on 8/4/15 were 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 services at issue were 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: Medical Necessity
Decision: Overturned

Summary  
The patient is a 27-year-old female with a history of severe adolescent idiopathic scoliosis with 
trunk rotation asymmetry, trunk shift, and associated pain. The patient was diagnosed with 
scoliosis at 13 years of age. The provider has recommended treatment with surgical correction of 
the patients scoliosis. The Health Insurer has denied the requested surgery as not medically 
necessary for the treatment of the patients medical condition. This denial is the subject of this 
appeal and determination. The physician reviewer found that the records provided for review 
indicate that the patient has a history of severe adolescent idiopathic scoliosis. According to Kuznia 
and colleagues, Patients with severe scoliosis (Cobb angle of 40 degrees or more) may have 
physical pain, cosmetic deformity, psychosocial distress, or, rarely, pulmonary disorders. The 
authors note that surgical correction of scoliosis should be reserved for severe cases, while 
conservative treatment may be effective for mild to moderate scoliosis. Per Yang and colleagues, 
Surgical  management  of  adolescent  idiopathic  scoliosis  can  be  performed  using  standard 
posterior spinal fusion or with a posterior minimally invasive approach. The benefits of the 
requested surgical procedure are further corroborated by Nishida and colleagues, who concluded 
that, Posterior correction and fusion surgery have improved preoperative asymmetric global 
rotational kinematics of trunk and pelvis in transverse plane to symmetric postoperatively in 
adolescent idiopathic scoliosis patients with thoracic single major curve. In this case, the patient 
has a history of severe scoliosis with a Cobb angle of 66 degrees as measured from the superior 
endplate at T8 to the inferior endplate at L2. There is a lack of additional imaging demonstrating 
any other significant spinal deficits that could be contributing to the patients pain. The patient has 
undergone physical therapy without adequate benefit. The peer-reviewed literature supports that 
conservative treatment is not as effective as surgical correction in severe cases of scoliosis. 
Without surgical correction, the patients severe curve is likely to progress and further affect her 
pulmonary function. Moreover, an initial perioperative hospital stay is indicated and supported for 
lumbar fusion procedures as recommended for this patient. For these reasons, the requested 
arthrodesis, anterior, for spinal deformity with or without cast, and anterior instrumentation with 
an inpatient stay are medically necessary for the treatment of the patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 62-year-old male who was diagnosed with Eustachian tube dilatory dysfunction and significant middle ear pressure. The patient has requested reimbursement for endoscopic balloon dilation of the Eustachian tube performed on 12/04/20. 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 the submitted documentation supports the medical necessity of the services at issue. The patient has a history of ear plugging due to chronic Eustachian tube dysfunction and has been unresponsive to medical therapy. Balloon Eustachian tuboplasty has been approved by the U.S. Food and Drug Administration. This procedure has been demonstrated to be effective in a randomized clinical trial with one-year follow-up. There is sufficient support for the services at issue in this patientas case. Therefore, endoscopic balloon dilation of the Eustachian tube performed on 12/04/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, the DecisionDx Melanoma testing (CPT code 84999) performed on 1/23/17 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: Upheld

Summary  
The patient is a 52-year-old female with a history of Graves disease and post-COVID symptoms 
including fatigue, brain fog, and varying degrees of shortness of breath. The patient underwent 
flow cytometry on 2/23/23 as workup for her long COVID symptoms. The Health Insurer has 
denied the services at issue as not medically necessary for the evaluation of the patients medical 
condition. This denial is the subject of this appeal and determination. The physician reviewer found 
that the records provided for review reflect that this patient underwent flow cytometry on 2/23/23 
as workup for her post-COVID conditions. No laboratory test can definitively distinguish post-
COVID conditions from other conditions with similar symptomatologies but different etiologies. 
The use of flow cytometry to assess cell surface markers and cytokine expression in patients with 
long  COVID  is  being  investigated  in  research  settings to  elucidate  the  pathophysiology  of 
inflammation in the setting of long COVID. However, there are no existing clinical applications 
of flow cytometry results for patients with long COVID. Inflammatory markers are generally not 
recommended for the workup of patients with suspected or confirmed long COVID. Therefore, the 
laboratory services flow cytometry performed on 2/23/23 were not medically necessary for the 
evaluation of the patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 63-year-old female enrollee has requested authorization and coverage for LINX Reflux Management System, CPT code 43284. 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 LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. Appropriate patient selection is crucial before anti-reflux procedures. This patient has gastroesophageal reflux disease based on pH recordings. Aside for situations of diet indiscretion, the patient reports appropriate benefit from acid suppression treatment, and accordingly, she cannot be considered medically refractory to acid blocker drugs. In this patients case, implantation of the LINX device must be approached with caution, particularly since there are documented complaints of difficulty swallowing and a normal lower esophageal sphincter anatomy and function that does not warrant augmentation. As such, LINX cannot be considered more beneficial for treatment of the patients condition than appropriate diet and lifestyle modification in combination with her presently effective acid suppression medications. Therefore, the LINX Reflux Management System (CPT 43284) is not likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 39-year-old female has requested reimbursement for Anser ADA testing performed on 6/25/15. 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 there is a lack of support for the services at issue in this clinical setting.  There is insufficient evidence to support the use of Anser ADA testing.  Studies performed thus far have included retrospective cohorts or have employed an observational design. There is a need for randomized controlled trials of tumor necrosis factor level and antibody driven care versus standard of care.  Therefore, Anser ADA testing performed on 6/25/15 was not likely to have been superior over other methods of evaluating this patient.  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.