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

Summary Reviewer 

The parent of a 14-year-old female enrollee has requested reimbursement for acute psychiatric inpatient treatment provided from 10/19/18 through 11/02/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining necessary level of care for children. As of 10/24/18, with regards to risk of harm, the records support a score of 2 due to a lack of a history of suicidal ideation but behaviors, including refusal to eat, which could cause self-harm, even unintentionally. In terms of functional status, the records support a score of 3. The records indicated that the patient had issues with role performance due to psychiatric symptoms. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2. In terms of level of stress of the recovery environment, the records support a score of 2. The patient had a stable living environment. With regards to resiliency and treatment history, the records support a score of 3. There was no clear evidence of long-term treatment outcomes. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy and followed the meal plan as directed. With regards to acceptance and engagement of the parent, the records support a score of 2. The patients parents worked actively and constructively with clinicians. Thus, the patient had a composite score of 16. This score correlates with intensive outpatient services. Thus, acute psychiatric inpatient treatment provided from 10/19/18 through 10/24/18 was medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of the remaining dates of services at issue. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 66-year-old female enrollee has requested reimbursement for the computed tomography (CT) of the chest with contrast and CT of the abdomen and pelvis with contrast provided on 10/19/17.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees uterine cancer. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines support the preoperative use of CT of the chest, abdomen and pelvis for evaluation of possible metastases in patients with serous uterine cancer. In addition, the use of CT scans every six months for a course of two years are suggested per NCCN guidelines. The evaluation is designed to detect distant or local metastatic disease at the earliest possible stage in order to provide optimal treatment. All told, the CT of the chest with contrast and CT of the abdomen and pelvis with contrast provided on 10/19/17 were medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 52-year-old male enrollee has requested authorization and coverage for Otezla. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees plaque psoriasis. The physician reviewer found that this patient has a history of chronic plaque psoriasis. Per the records, he has tried and failed treatment with topical steroids. However, there is no medical documentation of a contraindication, intolerance or adverse effect to using the preferred agents, including methotrexate, acitretin, Enbrel, Humira, Stelara or Remicade. In this patients case, the provider noted that disease-modifying antirheumatic drugs are contraindicated due to high blood pressure. However, disease-modifying antirheumatic drugs are contraindicated in the instances of liver disease and certain liver infections (such as hepatitis B or C), not high blood pressure. The patients provider noted that biologic agents have been avoided due to coronary artery disease. However, biologic agents are contraindicated in the setting of congestive heart failure, not coronary artery disease. The conditions reported for this patient do not represent contraindications to the use of the preferred formulary agents. As there are other effective, preferred agents offered for the treatment of the patients chronic plaque psoriasis, the requested medication Otezla 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 53-year-old female enrollee has requested reimbursement for clinical chemistry test (84999) performed on 10/01/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, 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. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, clinical chemistry test (84999) performed on 10/01/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 60-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 8/04/16.  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 found that the Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were not described as particularly dense.  However, she had a questionable area of developing new architectural distortion in one breast.  In this setting, breast tomosynthesis is valuable in separating out overlapping structures and possibly demonstrating an otherwise occult mass.  Thus, breast tomosynthesis performed on 8/04/16 was likely to have been of greater benefit than 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for services (Foundation One testing) performed on 2/07/19. 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 Foundation One is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic drug would be useful. However, at this time, there is a lack of convincing evidence that the assay adds to the decision making ability or yields as result that is clinically useful in a significant number of patients. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. In sum, services (Foundation One testing) performed on 2/07/19 were not likely to have been more beneficial than other standard methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata. The physician reviewer found that Alopecia areata is autoimmune in nature and brings psychological manifestations as well as physical. The use of Xeljanz has shown some promise, with better results than any other available standard treatment, other than maybe long-term oral steroids, which are limited by their side effects. In this clinical setting, Xeljanz is likely to offer this patient the safest option to treat her ongoing disease. In sum, Xeljanz 5 mg are likely to be of greater benefit than other treatment modalities. Based upon the information set forth above, the requested medication is 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 

A 58-year-old male enrollee has requested authorization and coverage for right shoulder surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested services in this clinical setting. The patient has a history of right shoulder pain associated with an isolated SLAP tear. Non-operative treatment has been tried and failed. The provider is requesting arthroscopy and biceps tenodesis. Cvetanovich and colleagues performed a retrospective query from years 2007 to 2016 for the management of isolated SLAP tears. The treatments compared included debridement, SLAP repair, open or arthroscopic biceps tenodesis, and SLAP repair combined with biceps tenodesis. The analysis revealed that surgical treatment of isolated SLAP tears in the United States has shifted from 2007 to 2016, with an increase in the frequency of biceps tenodesis and decrease in the frequency of SLAP repair, particularly in patients older than 40 years. A review of the surgical results indicates that biceps tenotomy or tenodesis yields good results in this age group. The article by Fourman and colleagues noted that surgical repair of type VIII SLAP tears in the young athletes led to significant improvements in stability, pain, range of motion, and outcome scores at midterm follow-up, except in throwers in whom the results were not as good. These findings suggest that type VIII SLAP tears should be repaired in young athletes because outcomes do improve. However, in this patients age group, biceps tenotomy or tenodesis remains the procedure of choice. Therefore, the requested right shoulder surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 29-year-old male enrollee has requested authorization and coverage for Subsys. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting.   The requested medication is appropriate for breakthrough cancer pain relief.  While the patient does have documented chronic pain, he does not have a diagnosis of cancer.  The medical evidence does not support Subsys for the treatment of this patients condition.  Therefore, Subsys is not likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested medication 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 50-year-old male enrollee has requested reimbursement for the DecisionDx melanoma assay provided on 8/19/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees thin melanoma.   The physician reviewer found that melanoma staging is characterized by the American Joint Committee on Cancer (AJCC). While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin exams and clinical examination. The DecisionDx melanoma gene expression profile (GEP) test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. DecisionDx melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1 consistent with a low risk of metastasis or class 2 suggestive of a high risk of metastasis. One peer-reviewed publication indicated that there was a statistically significant association of a class 1 signature by DecisionDx melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently class 2 (Sidiropoulos, et al). The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. However, there is a lack of peer-reviewed published studies confirming improved health outcomes with use of this assay over standard testing. Thus, the DecisionDx melanoma assay provided on 8/19/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 50-year-old female enrollee has requested authorization and coverage for ultrasound ablation. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees uterine fibroids. The physician reviewer found the request for ultrasound ablation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although there is some medical literature that suggests MR-guided high intensity focused ultrasound is a promising technique, there is a lack of peer-reviewed literature that shows increased effectiveness of this technique compared to other currently available minimally invasive techniques, such as uterine fibroid embolization. In addition, there is a lack of documentation provided that indicates that patient would not be a suitable candidate for uterine fibroid embolization or other traditional standard of care treatments. For these reasons, the requested 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 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found the medical records fail to demonstrate the superior efficacy of the device at issue in this clinical setting.  In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy, and there was no documented indication for immediate placement of a defibrillator, such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction less than or equal to 35%) is documented to persist despite of appropriate treatment. A prophylactic defibrillator, either wearable or implantable, before this time has not been demonstrated to improve outcome. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation.  Per the current evidence, the wearable cardioverter defibrillator was not likely to have been of greater benefit than other treatment options. Based upon the information set forth above, the device 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 2

The parent of a 14-year-old male enrollee has requested authorization and coverage for the ReWalk Exoskeletal Device durable medical equipment (DME). The Health Insurer has denied this request indicating that the requested equipment is investigational for treatment of the enrollees T8 incomplete spinal cord injury due to spinal tumor.  The physician reviewer found the current peer-reviewed medical literature supports the requested ReWalk Exoskeletal Device as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Miller and colleagues noted that, powered exoskeletons allow patients with spinal cord injury to safely ambulate in real-world settings at a physical activity intensity conducive to prolonged use and known to yield health benefits. Asselin and colleagues reported that paraplegic patients were able to ambulate efficiently using the powered exoskeleton for overground ambulation, providing the potential for functional gain and improved fitness. The clinical documentation submitted for review indicated the patient had a spinal cord injury due to a cancerous tumor. The patients cancer was in remission. The patient was in a wheelchair. The patient had reduced lung capacity. The patient had a successful trial of the unit with an improved ability to ambulate and to transfer from one position to another. The peer-reviewed literature indicates that exoskeletons such as the ReWalk device may allow patients to ambulate with a normal velocity and may assist the patient to have improved fitness. An upright posture may also permit this patient to have an increase lung capacity, whereas, continual sitting in a wheelchair has led to decreased lung capacity. According to the support in the medical literature as well as this patients performance with a trial with the requested device, the ReWalk Exoskeletal Device is 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 equipment is 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 34-year-old male who has been diagnosed with ulcerative colitis. The patient has requested authorization and coverage for Simponi 100 mg every 21 days. The Health Insurer has denied this request and reported that the requested medication regimen is not medically necessary for the treatment of this patient.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. The randomized PURSUIT study showed that Simponi serum concentrations are proportional to dose, and higher Simponi concentration was associated with improved clinical outcomes. Studies have shown that dose escalation can recover response to therapy in a significant fraction of patients. One study showed recovery of response in 71% of ulcerative colitis patients undergoing Simponi dose escalation, and another demonstrated improvement in half of patients (Taxonera and Rodriguez, et al; Taxonera and Iborra, et al). In this case, the patient has failed the standard dose of Simponi, with symptoms of active disease, and elevated fecal calprotectin. Dose escalation can recover response and prevent complications, such as disease flare, hospitalization, toxic megacolon, and dysplasia with risk of colorectal cancer. Therefore, Simponi 100 mg every 21 days is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 43-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/14/18. 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 the prognosis of cutaneous melanoma is classically evaluated by the staging system spelled out by Balch. Mitotic rate may add to these statistics. DecisionDx-Melanoma testing is a 31-gene panel of an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between DecisionDx-Melanoma classification and prognosis, in patients who had had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch statistics. Most importantly, it is not clear if DecisionDx-Melanoma testing can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 2/14/18 was not 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 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.