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

Summary Reviewer 2
A 54-year-old female enrollee requested authorization and coverage for arthrodesis sacroiliac joint percutaneous. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees bilateral sacroiliitis. The physician reviewer found A study by Polly and colleagues involved a randomized controlled trial of minimally invasive sacroiliac joint fusion using triangular titanium implants compared to nonsurgical treatment at 12 months. A total of 148 patients with sacroiliac joint dysfunction were randomly assigned to minimally invasive sacroiliac joint fusion with triangular titanium implants or nonsurgical treatment.  The conclusion was that this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management at one year in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction caused by degenerative sacroiliitis or sacroiliac joint disruptions.  Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment. In another recent article in the International Journal of Spine Surgery in March 2015, sacroiliac joint fusion using triangular titanium implants was compared to nonsurgical management at six months with a prospective randomized controlled trial.  The conclusions were that six month follow up from this level one study showed that minimally invasive sacroiliac joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with sacroiliac joint dysfunction due to degenerative sacroiliitis or sacroiliac joint disruptions.  Based upon a review of the recent literature, the requested minimally invasive sacroiliac joint fusion is appropriate in this clinical setting. There are enough studies in the literature to prove that the procedure is effective as a treatment option for patients diagnosed with bilateral sacroiliitis. As such, bilateral minimally invasive arthrodesis sacroiliac joint percutaneous is likely to be more effective for treatment of the patients medical condition than any available standard modality.
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: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 19-year-old female who presented to her provider with complaints of headache, lock jaw, dizziness and numbness. The documentation provided for review states the patient was treated for possible Lyme disease, but her symptoms persisted. The provider recommended further investigation for Vector-borne disease and rheumatoid diseases. The patient has requested reimbursement for infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and methylenetetrahydrofolate reductase (MTHFR) inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational. The appropriate laboratory testing for Lyme disease is with two-step testing, using first step EIA, and second step immunoglobulin G (IgG) and immunoglobulin M (IgM) immunoblots, if the first step is positive or equivocal. According to the guidelines of the Infectious Diseases Society of America (IDSA), use of polymerase chain reaction (PCR) of blood is not recommended in this clinical setting (Wormser, et al). PCR assay of blood has low sensitivity because of the short duration of spirochetemia (Lantos, et al). According to the Centers for Disease Control and Prevention (CDC), PCR testing of blood for Lyme disease lacks clinical sensitivity and has increased potential for contamination. The CDC noted that PCR on blood has not been universally standardized or optimized for diagnosis of Lyme disease (Moore, et al). Additionally, the MTHFR inhibitor gene analysis was not indicated. There was no history to suggest a hypercoagulable risk such as pulmonary embolism or deep venous thrombosis. Moreover, the current peer-reviewed medical literature has not established an association of this gene with hypercoagulable state or other clinical syndrome. Thus, MTHFR testing provided was not likely to be more beneficial for evaluation of this patients medical condition than any available standard testing.                                                                                                                                                             Given these findings, the infectious agent detection by nucleic acid, multiple organisms; amplified probe(s) technique, infectious agent detection by nucleic acid, not otherwise specified; amplified probe(s) technique, and each organism and MTHFR inhibitor gene analysis, common variants testing provided on 7/5/17 and 9/19/17 were 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: Overturned

Summary Reviewer 3 
 
A 74-year-old male enrollee has requested reimbursement for laboratory testing provided on 
10/12/20. 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 in this case, prognostic analysis conducted on the biopsy specimen showed 
a gain of chromosome 6p which puts the melanoma at low risk. There is no indication for a 
gene expression assay to determine systemic imaging surveillance. The recommendation is for 
imaging to evaluate signs and symptoms as clinically indicated and to consider imaging every 12 
months due to the low risk profile. Per the National Comprehensive Cancer Network guidelines, 
a gain of chromosome 6p deems the melanoma low risk. Since the patients biopsy yielded a 
gain of chromosome 6p, gene expression profiling was not indicated. Therefore, laboratory 
testing provided on 10/12/20 was not likely to have been more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 36-year-old female insured has requested reimbursement for laser hair removal performed on 
10/25/22. A review of the record indicates that the insured was diagnosed with hidradenitis 
suppurativa at the axillae and groin two years ago, which worsened with pregnancy. The Health 
Insurer indicates the services at issue were considered investigational for the treatment of the 
insured's medical condition. Therefore, the Health Insurer has denied reimbursement for the 
services at issue. This denial is the subject of this appeal and determination. The physician reviewer 
found that there are several options for the treatment of patients with hidradenitis suppurativa, 
including pharmacological, surgical, and other modalities. For moderate-to-severe hidradenitis 
suppurativa, adalimumab is U.S. Food and Drug Administration (FDA) approved for treatment 
(Kimball, et al.; Jemec, et al.). While laser hair removal has emerged as a potential treatment 
option, there is a lack of quality evidence for specific laser modalities. Minimal evidence supports 
the use of alexandrite laser treatment for the treatment of patients with hidradenitis suppurativa. 
One small study exploring the use of alexandrite laser treatment for the treatment of patients with 
hidradenitis suppurativa showed some potential therapeutic benefit (Molinelli, et al.). Another 
larger  randomized  trial  of  laser  hair  removal  for  the  treatment  of  hidradenitis  suppurativa 
demonstrated efficacy in the reduction of inflammatory lesions but did not report an effect on 
disease flares (Naouri, et al.). In this case, the patient has a history of chronic hidradenitis 
suppurativa. The patient underwent alexandrite laser hair removal, which the medical literature 
has not established as an effective treatment option for the reduction of disease flares in patients 
with hidradenitis suppurativa. Given these findings, the laser hair removal performed on 10/25/22 
was not likely to be more beneficial for the treatment of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services provided from 1/31/17 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 issues. The physician reviewer found that the records provided for review do not support the medical necessity criteria for RTC services from 1/31/17 forward for treatment of this patients behavioral health issues. The patient did not demonstrate behaviors suggesting that he was at imminent risk of harm to self or others. The patients psychiatric issues prompting admission could have been safely and efficiently been treated at a less intensive setting. The patient has also not shown to have any acute impairment in 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 did not undermine engagement at a less intensive level of care, such as outpatient care. All told, the patient did not require 24-hour supervision and management at the RTC level of care from 1/31/17 forward. Based on the foregoing discussion, the services at issue were not and are 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 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the services at issue were likely to be more effective for this patient than other available treatment options. The treatment of atrial fibrillation with catheter ablation has undergone changes during the past 10 years with evaluation of new technology. The Heart Rhythm Society gave a Class I status to the procedure at issue in patients with structurally normal heart and paroxysmal atrial fibrillation who have failed one or more type I or type III anti-arrhythmic drugs (Calkins, et al). This was based on review of at least eight randomized trials and other non-randomized trials. The STOP-AF trial was published in April 2013 and showed good success rate and improved patient symptoms with cryoablation for paroxysmal atrial fibrillation, compared to conventional therapy (Packer, et al). In addition, the American College of Cardiology guidelines in 2014 gave a Class I status to catheter ablation for symptomatic paroxysmal atrial fibrillation when individuals had failed one or more type I or type III anti-arrhythmic medications (January, et al). In sum, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 33-year-old male who was noted to have a 6.1 cm mass in the right lower lobe of his lung on 5/18/18. On 6/08/18, a diagnosis of adenocarcinoma was made. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The National Comprehensive Cancer Network (NCCN) recommends obtaining a brain MRI before proceeding with additional chemotherapy after diagnosing advanced metastatic non-small cell lung cancer (NSCLC). Pechoux and colleagues noted, In patients with more advanced (stage IIIA/N2) NSCLC who underwent surgical resection, those who had adenocarcinoma histology and
preoperative chemotherapy seem to have an increased risk of developing brain metastases (>30%). At the same time, there is literature suggesting that early detection of further metastases does not alter the course of disease. As written by McMurry, representative data provide evidence that more frequent post-surgical surveillance is not associated with improved survival. As the number of lung cancer survivors increases over the next decade, surveillance is an increasingly important major health care concern and expenditure. In this patients case, he would not have been able to participate in a clinical trial without a new brain MRI. This is common in clinical trials. In order to have an effective clinical trial, there are always strict criteria for admission. In conclusion, while one could argue that another MRI of the brain is not warranted simply prior to routine chemotherapy, the MRI dated 6/18/19 allowed the patient to participate on the trial, and hence, altered his immediate therapy. Therefore, MRI of the brain provided on 6/18/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 48-year-old male enrollee has requested reimbursement for a test used to adjust treatment for obstructive sleep apnea performed on 2/09/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation supports the medical necessity of the services at issue.  Per the medical records, the patient has a history of sleep apnea.  The medical notes indicate that the patient needs to be on CPAP.  The current medical evidence supports the services performed on 2/09/15.  Failure to performed the study at issue have may lead to adverse health problems for the patient.  All told, the test used to adjust treatment for obstructive sleep apnea performed on 2/09/15 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: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 25-year-old female with a history of chronic sinus problems. The provider reports the patient presented with symptoms of recurring sinus infections requiring antimicrobial treatment four times in the preceding four months. The patients symptoms included facial pressure, headache, generalized fatigue and nasal congestion. The physical examination documented clear mucus and nasal septal deviation suggestive of acute rhinitis, most likely to be of bacterial origin and the provider recommended use of a topical fluticasone nasal spray and nasal irrigations along with computed tomography (CT) imaging of the paranasal sinuses. On 2/13/18, a follow-up note documented that the patient had been evaluated for nasal airway obstruction due to deviated nasal septum and rhinorrhea. CT imaging on 12/27/16 demonstrated that the frontal, ethmoid, maxillary and sphenoid sinuses were clear and that the sphenoid and frontal sinuses were found to be hypoplastic. The ostiomeatal units were found to be patent. This was in comparison to the previous CT scan dated 8/18/16. The patient has requested reimbursement for the CT maxillofacial without contrast material provided on 12/27/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary. Upon the review of the documentation, the provider stated in the physical examination that the patient did have symptoms of recurrent acute sinusitis over four months or longer and had been placed on multiple different medical therapies including antibiotics and other medications, but still had repeated rhinosinusitis. The patient was found on physical examination to have persistent rhinorrhea in addition to nasal septal deviation, which is one of the physical findings on examination to meet criteria for CT scan imaging. Practice guidelines acknowledge that CT imaging, as opposed to the plain radiography or magnetic resonance imaging (MRI), is the diagnostic modality of choice for confirming chronic rhinosinusitis or as an alternative to nasal endoscopy. Thus, the CT maxillofacial without contrast material provided on 12/27/16 was medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the diagnostic procedure at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 62-year-old male with irritant dermatitis. Per the provider, the patient is a candidate for treatment with Urea 40% cream. The patient has requested authorization and coverage for Urea cream. The Health Insurer has denied this request indicating that the requested medication is not medically necessary.The records indicate that this patient has tried and failed therapy with topical steroids and long-term usage of such is contraindicated due to risks of skin atrophy. Urea 40% cream is a keratolytic agent that helps to reduce a build-up of scale and adherent skin, and is not considered a typical agent for the treatment of irritant dermatitis. Moreover, a prescription is not needed for this medication as Urea 40% cream can be obtained over the counter. All told, the requested Urea cream is not supported as medically necessary for treatment of this patients medical condition. 

Based on the foregoing discussion, 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 3

A 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that based on the records provided, the patient is a 38-year old male with unexplained anemia. Although elevated homocysteine levels have been associated with anemia, an elevated homocysteine level does not point to a specific cause of the anemia (den Elzen, et al). Moreover there is a lack of clinical trials that demonstrate outcome improvement with treatment targeted at reducing homocysteine levels (Lonn; Toole, et al). Likewise, even though results of homocysteine levels may be abnormal and considered independent risk markers for coronary disease, there is a paucity of scientific data demonstrating outcome benefits by treating routinely obtained abnormal results. Thus, the homocysteine testing provided on 9/5/14 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, I have determined 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 3

A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found that although the shingles vaccine is approved for adults over the age of 50, it is generally not recommended until over the age of 60 due to concerns regarding long-term effectiveness. There is some advice regarding earlier administration in patients who would not be expected to tolerate a shingles outbreak, such as patients with a chronic skin condition or chronic pain. This patient is not in this category. In addition, it is recommended for patients over the age of 50 who are receiving immunosuppressive therapy. In this patients case, the medical records do not indicate she is receiving immunosuppressive therapies for the treatment of her rheumatoid arthritis. The current guidelines do not suggest earlier administration of the vaccine on the basis of rheumatoid arthritis. Thus, the shingles vaccine performed on 2/06/17 was not likely to have been more efficacious than other available treatments. 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/06/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found the current medical evidence supports the service at issue in this clinical setting.  According to Skaane and colleague, 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 noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed on 7/06/16 was likely to have been more effective 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.