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

Summary Reviewer 3


A 59-year-old female enrollee has requested reimbursement for a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical evidence has not established the superior efficacy of the device at issue.  The use of icepacks has been in regular and common use for decades.  In this patients case, there is a lack of evidence indicating that the device at issue was likely to have been more effective than simpler methods of applying cold, such as icepacks.  Per the medical literature, simpler applications of cold have been demonstrated to be equally efficacious.  Therefore, the device at issue 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 3


A 55-year-old female enrollee has requested authorization and coverage for botulinum toxin type A (Botox) treatment and ongoing treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that although Botox is not indicated for every patient with a migraine disorder, it can provide relief in a subset of patients and is U.S. Food and Drug Administration (FDA) approved for this indication. In this particular case, the patient failed multiple first-line therapies and had a documented response to Botox. While not treated with Botox she experienced a significant worsening of her headache frequency. For these reasons, the requested ongoing treatment with Botox 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 services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 67-year-old female enrollee has requested authorization and coverage for Actemra injections 80 mg/4 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 in this case, the patient has active, moderate to severe rheumatoid arthritis. She is being treated with prednisone with a history of ongoing osteoporosis. She experienced side effects from the prednisone with multiple fractures. She has failed two different TNFi medications including Enbrel which was ineffective and Humira which caused an adverse reaction. She is noted to have been tuberculosis negative prior to previous TNFi and most recent chest x-ray on 5/11/17 was also negative for tuberculosis. She has failed two TNFi and the guidelines suggest a decreased response to a third TNFi after poor response or inability to use a second TNFi. As such, the request for Actemra injections 80 mg/4 mL is supported as medically necessary for treatment of this patients rheumatoid arthritis. Based on the foregoing, 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 


An 18-year-old male enrollee has requested reimbursement for mental health residential treatment center (RTC) services provided from 7/6/15 through 6/28/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees major depressive disorder and anxiety disorder. The physician reviewer found that the records provided for review do not meet the medical necessity criteria for the mental health RTC level of care services provided from 7/6/15 through 6/28/16. Overall, the patient did not require 24-hour a day seven days per week supervision. The patient did not appear to be at imminent risk of harm to self or others. Psychiatric issues prompting his admission including depression and irritability could have been safely and efficiently been treated at a less intensive treatment setting. There also was no evidence of any acute impairment, behavior, or issues with cognition that interfered with activities of daily living. Psychosocial and environmental problems were not likely to threaten the patients safety and would not likely have undermined engagement at a less intensive level of care, such as outpatient care. On 7/10/15, the patients individual therapy note reported the patients mood was normal and his affect was blunted. On 7/28/15, he had a significant reduction in crying spells since admission to the program. On 8/10/15, he continued to report irritability. Such treatment issues are those routinely treated in an outpatient clinic and did not require RTC services to be managed effectively. Further, medication changes made during this time did not require RTC level of care and supervision. Depakote was reduced and Seroquel was increased due to low neutrophils. It was also noted he repeatedly was not using his continuous positive airway pressure (CPAP) routinely including on a progress note dated 11/18/15. However, the medication management could have been adequately addressed on an outpatient basis and the use of CPAP could have been supervised by his caregiver at home. On 12/30/15, it was noted that his home visit did not go well. It was reported he had low frustration tolerance and poor mood regulation. However, these issues did not warrant ongoing residential treatment. Moreover, on 5/29/16 it was noted that the patient had no suicidal or homicidal ideations, had no mania, no psychosis, and no agitation. All told, the mental health RTC services provided from 7/6/15 through 6/28/16 were not medically necessary for treatment of this patients behavioral health issues. 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the presence of breast implants and the family history of breast cancer are not automatic indications for tomosynthesis. However, the patients breasts are extremely dense, and patients with dense breasts can benefit most from tomosynthesis. The ability to separate overlapping breast tissues and better demonstrate an occult tumor is one of the primary benefits of tomosynthesis. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/9/16 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 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 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. 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 this patient had two prior early miscarriages. As a result, her provider ordered multiple genetic blood tests for inherited thrombophilias. The use of these tests to evaluate women with prior miscarriages is not supported by available literature. An extensive literature review has shown a lack of association of heterozygosity of the MTHFR mutation and miscarriage. Rey and colleagues concluded, aMethylenetetrahydrofolate mutation, protein C, and antithrombin deficiencies were not significantly associated with fetal loss.a The American College of Obstetricians and Gynecologists does not recommend screening for this in non-pregnant or pregnant women. Thus, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 29-year-old female enrollee has requested reimbursement for the human papilloma virus (HPV) testing provided on 8/26/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for HPV. The physician reviewer found that according to the recommendations from the American College of Obstetrics and Gynecology (ACOG) and the American Society for Colposcopy and Cervical Pathology (ASCCP), women aged 21-29 years should have a Pap test alone every three years and HPV testing is not recommended. The guidelines further recommended that women ages 30-65 years should have a Pap test and an HPV test (co-testing) every five years. It also is acceptable to have a Pap test alone every three years. From the chart and patient statements, the HPV testing performed at this patients postpartum visit was not clinically indicated for evaluation of this patients medical condition. There was no medical record documenting any previous normal or abnormal Pap smear testing. Overall, the current guidelines only support an indication for the Pap smear, not the HPV testing. Thus, the HPV testing provided on 8/26/16 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: Experimental
Decision: Upheld

Summary Reviewer 3


The parent of a 14-year-old male enrollee has requested authorization and coverage for surgery for scoliosis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that standard interventions for adolescents and adults, including spinal deformity correction and fusion, may not be appropriate for young patients with considerable growth remaining. Preliminary outcomes for fusionless spine surgery are promising, but further investigation, including long-term follow-up, is necessary. In addition, the requested technique is not the standard of care in this clinical setting. Vertebral body stapling, a fusionless treatment option, has been shown to be effective in controlling curve progression in the high-risk group of children younger than 10 years with idiopathic scoliosis between 30 and 39 degrees in whom bracing may be ineffective (Theologis, et al). Therefore, surgery for scoliosis 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 services are 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 1

A 58-year-old female enrollee has requested authorization and coverage for the LINX device.  The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. 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 best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al; Ganz). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX device 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: Overturned

Summary Reviewer 1

A 46-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has obstructive sleep apnea. The drug induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse at the velum and tongue base/epiglottis. The patient has not been able to tolerate the APAP device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to APAP, anterior posterior collapse, no central apnea, and body mass index (BMI) and apnea-hypopnea index (AHI) within FDA criteria. There is sufficient support for the requested services in this clinical setting. Therefore, hypoglossal nerve stimulation or Inspire Upper Airway Stimulation System is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 31-year-old female with a history of vitiligo. She was previously treated with narrowband ultraviolet B (UVB) without success. The physician reviewer found that Vitiligo is an autoimmune disease, evidenced by circulating melanocyteaspecific antibodies, and association with other autoimmune diseases. At present, no medical treatment for repigmenting vitiligo has been approved by the U.S. Food and Drug Administration (FDA), and therefore treatments are used off-label. Topical treatments may be applied alone when small areas are involved or when other treatment modalities are not readily available. This patient has failed to repigment with topical treatment alone. Phototherapy combined with topical treatment is preferred when greater than 5-10% of the body surface area is affected. The use of targeted phototherapy, excimer laser, is preferred when there is limited disease, as this limits the exposure of the skin from unwanted side effects of total body ultraviolet treatment. Targeted narrowband UVB in the form of excimer laser is considered standard therapy. Therefore, CPT codes 96920, 96921 and 96922 (laser treatment for skin disease) are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 27-year-old male enrollee has requested reimbursement for laboratory services (81243, 88230, 88262, 88289) provided on 10/19/18. 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 there is a lack of support for the services at issue in this clinical setting. Per the records, the laboratory services in dispute are 88230, tissue culture for non-neoplastic disorders, lymphocyte, 88262, chromosome analysis, count 15-20 cells, two karyotypes, with banding, 88289, chromosome analysis, additional high resolution study, and 81243, fragile X (FMR1). Codes 88230, 88262 and 88289 can be grouped together, as the tissue culture is needed for chromosome analysis. In this patients case, it is unclear why the provider ordered both standard chromosome analysis and high resolution chromosome analysis, but neither were indicated. The providers notes state that this was ordered due to the patients sisters infertility and his mothers miscarriages. Either of these would be indications for chromosome analysis in the affected individual, but are not indications for analysis in this patient. With regards to 81243, the notes indicate that this was ordered due to a history of anxiety, depression, and obsessive-compulsive disorder in the patient, family history of autistic-like behaviors in the patients brother, and family history of psychiatric illness. This testing was not indicated. Fragile X is a common cause of significant intellectual disability and autism spectrum disorders, not reported in this patient (or his brother with autistic-like behaviors but high intelligence). Males with fragile X will have significant developmental concerns, which this patient does not have. Psychiatric illness alone is not caused by fragile X full mutations or pre-mutations. While his sisters infertility may be an indication for testing her if she has premature ovarian failure, testing this patient was not indicated. Therefore, laboratory services (81243, 88230, 88262 and 88289) provided on 10/19/18 were not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 26-year-old male enrollee has requested authorization and coverage for Ocrevus injections 300/10 mL. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees relapsing-remitting multiple sclerosis. The physician reviewer found the submitted documentation supports the medical necessity of the requested medication. The Health Insurer has offered glatiramer acetate and fingolimod (Gilenya) as alternatives. However, this patient has reportedly failed a trial of glatiramer acetate. The records document that the patient tested positive for JC virus. Medications such as Gilenya and Tysabri are contraindicated for patients with positive JC virus titers. There is greater potential for risk of progressive multifocal leukoencephalopathy, an often opportunistic infection from JC virus, in patients treated with Gilenya. The current medical evidence supports the requested medication in this patients case. All told, Ocrevus injections 300/10 mL are 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: Experimental
Decision: Upheld

Summary Reviewer 3 
A 75-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 5/26/21. 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 per the National Comprehensive Cancer Network guidelines, the 
recommended therapy for stage IB cutaneous melanoma is history and physical and only 
imaging to evaluate certain signs and symptoms. The recommended primary category 1A 
treatment is wide excision of the melanoma and to discuss and offer sentinel lymph node 
biopsy. Furthermore, the guidelines state, For stage IB (pT2a) melanoma, the probability of a 
positive sentinel lymph node is greater than 10%. There is no indication for a gene expression 
assay to determine the primary course of treatment as sentinel lymph node biopsy should be 
offered with the above case. Marchetti and colleagues concluded, The prognostic ability of 
GEP tests among patients with localized melanoma varied by AJCC stage and appeared to be 
poor at correctly identifying recurrence in patients with stage I disease, suggesting limited 
potential for clinical utility in these patients. Therefore, DecisionDx-Melanoma testing 
performed on 5/26/21 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 26-year-old female enrollee has requested reimbursement for CPT code 81291 performed on 10/11/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a family history of a clotting disorder. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Knowledge of the patients MTHFR status does not impact her care during pregnancy. All pregnant patients are advised to have adequate folic acid intake to prevent neural tube defects.  There is no recommended treatment during pregnancy for a known mutation in the MTHFR gene. Thus, the superior efficacy of CPT code 81291 performed on 10/11/17 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.