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

Summary Reviewer 


A 37-year-old male enrollee has requested authorization and coverage for Afinitor 5 mg one tablet daily. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees anaplastic ependymoma. The physician reviewer found that the records provided for review document that this is a patient with refractory ependymoma. The treating provider has recommended treatment with Afinitor. However, there is a lack of peer-reviewed medical literature supporting the effectiveness of Afinitor in this clinical setting. The available data on the use of Afinitor in patients with ependymoma is not single agent use data. In addition, the available reports are phase 1 data. Moreover, the National Comprehensive Cancer Network (NCCN) guidelines do not include Afinitor as an active agent in the treatment of ependymoma. All told, Afinitor may subject a patient to significant toxicities, which suggests its use should not be performed outside of a clinical trial.  Accordingly, the requested Afinitor 5 mg, one tablet daily, is not 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: Upheld

Summary Reviewer 3

A 46-year-old female enrollee has requested reimbursement for Botox injections provided on 7/8/15 and 11/6/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found review of the submitted documentation and relevant literature fails to support the use of Botox injections in this clinical setting. The documentation submitted for review fails to adequately detail the patients headache symptoms to determine if she has migraine, or cervicogenic headache due to chronic neck issues. There is a lack of documentation to confirm a diagnosis of migraine or chronic migraine. Moreover, the medical literature indicates that Botox is not effective for episodic migraine or cervicogenic headache. In sum, based on the documentation submitted, the Botox injections provided on 7/8/15 and 11/6/15 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 56-year-old male enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 11/14/18. 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 melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 11/14/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 61-year-old female enrollee has requested authorization and coverage for home health aide services eight (8) hours per day three (3) days per week (Monday, Wednesday, Friday). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees hemorrhagic stroke with left-sided hemiparesis. The physician reviewer found that per the reviewed literature, a providers orders for services in the plan of care must specify the medical treatments to be furnished as well as the type of home health discipline that will furnish the services and at what frequency the services will be provided. This patients documentation states that the provider noted that health aide services eight hours per day three days per week (Monday, Wednesday, Friday) are medically necessary and reasonable given the patients deficits and complex medical history. This patient has left-sided hemiparesis and sustained a fall resulting in left radial/ulnar fracture which will require surgery. She remains at risk for subsequent falls and requires assistance with all activities of daily living. Given these findings, the requested home health aide services eight (8) hours per day three (3) days per week (Monday, Wednesday, Friday) are supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing performed on 10/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient underwent a multilevel cervical discectomy and fusion procedure with instrumentation. Intraoperative neurophysiologic monitoring was performed during the procedure to include automated nerve conduction testing. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this testing. According to the technological review, Morse concluded that the diagnostic accuracy of NC-stat (automated nerve conduction testing) is not yet demonstrated in the scientific literature to be equivalent to traditional or gold-standard testing methods. Moreover, the study by Schmidt and colleagues concluded that the automated device accurately recorded raw data, but the interpretations provided were overly sensitive and lacked the specificity necessary for a screening or diagnostic examination. Therefore, the automated nerve conduction testing performed on 10/20/15 have not been established as 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: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 65-year-old male who has been diagnosed with prostate cancer. The records noted that he has castrate resistant prostate cancer status post systemic therapy using docetaxel, followed by enzalutamide and cabazitaxel. The disease has now progressed and the treating provider ordered a Guardant360 molecular test, which identified a MET proto-oncogene mutation. The treating provider stated that there are preclinical models suggesting that MET proto-oncogene mutations are a good target for cabozantinib. The patient has requested authorization and coverage for Cabometyx (cabozantinib) 60 mg #30/30. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of this patients medical condition. There is a lack of peer reviewed literature to support the requested medication in this clinical setting. As stated by the treating provider, there are preclinical models for potential activity in MET mutations. As such, the use of this therapy, outside of a well conducted clinical trial, is potentially harmful and may not generate meaningful conclusions. In sum, Cabometyx (cabozantinib) 60 mg #30/30 is not likely to be more effective than the available options for treatment of this patients medical condition. 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: Overturned

Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient has juvenile dermatomyositis which is moderate to severe and a biologic such as Remicade (infliximab) would likely be beneficial for this patient. Moreover, infliximab has been shown to be safe and effective in children with juvenile dermatomyositis. Riley and colleagues assessed the response of five refractory juvenile dermatomyositis patients to infliximab. The authors reported Improvements in all five patients as shown by positive changes in physician visual analogue scale (VAS), Childhood Myositis Assessment Score (CMAS), Childhood Health Assessment Questionnaire (CHAQ), joint range of movement and, in some, regression of calcinosis and skin signs. There were no major side effects observed with addition of infliximab to the therapeutic regime. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports a portion of the services at issue. Specifically, interlaminar epidural steroid injections were likely to have been more beneficial than other treatment options. However, there is a lack of support for transforaminal selective nerve root blocks. The description of these blocks in the operative reports indicates that these blocks were directed towards treating the facet joint pain, which is not the standard approach to the performance of medial branch blocks.  The approach and the quantity of medication utilized would likely result in treating much more than just the medial branches, making this non-diagnostic for facet joint syndrome. Even if the medial branch blocks were done in the standard, generally-accepted fashion, combining them with an epidural steroid injection that contained 5cc of bupivacaine and steroid, would make it impossible to differentiate the results of the various injections, thus making the medial branch blocks non-diagnostic. The primary goal of medial branch blocks is to determine whether radiofrequency ablation of the nerves is likely to result in relief of facet joint pain by demonstrating substantial temporary relief of the low back pain. Therefore, interlaminar epidural steroid injections (62311) were likely to have been more beneficial than other treatment modalities. However, the superior efficacy of the remainder of the services at issue has not been established.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 45-year-old female enrollee has requested reimbursement for FoundationOne gene testing performed on 3/26/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees adenosarcoma of the cervix.        The physician reviewer found the services at issue were likely more effective than any standard tests available for treatment of this patients uterine adenosarcoma. Uterine adenosarcomas are rare and generally treated similar to other endometrial stromal tumors. The prognosis is poor once it metastasizes. For patients with recurrent uterine adenosarcoma, there are few data to guide management. However, in this patient, she has exhausted conventional therapies, has a rare cancer and maintains a good functional status. The medical literature supports molecular testing, such as with FoundationOne, to assist in identifying potential markers to help guide 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: Experimental
Decision: Upheld

Summary Reviewer 3


A 39-year-old male enrollee has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found LINX Reflux Management System is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Lipham and colleagues performed a multicenter, prospective, single-arm study that included 44 patients who underwent a laparoscopic surgical procedure for placement of the LINX System around the gastroesophageal junction. The authors demonstrated efficacy up to four years in the reduction of the amount of pathologic esophageal acid exposure. The authors concluded that the magnetic device decreased exposure to esophageal acid, improved reflux symptoms, and allowed cessation of proton-pump inhibitors in the majority of patients. Additionally, the requested procedure is approved by the U.S. Food and Drug Administration (FDA). Based on the support in the medical literature cited above, the requested procedure is likely to 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: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 19-year-old female enrollee has requested reimbursement for a Papanicolaou (Pap) smear 
performed on 1/03/22. 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 the current medical evidence does not supports the services at issue in this 
clinical setting. This patient was seen by her provider at 19 years of age, and a Pap smear was 
performed. Pap smear in women under the age of 21 for routine screening is not indicated per 
multiple professional organizational opinions. It is not more beneficial for this patient to have a 
Pap smear than the standard treatment of waiting to screen for cervical cancer at age 21. 
Therefore, the Pap smear performed on 1/03/22 was not likely to have been more beneficial for 
evaluation of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 43-year-old female enrollee has requested authorization and coverage for right sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found that SI joint fusion has not been demonstrated in the peer-reviewed medical literature to provide superior health outcomes for treatment of low back pain. Overall, long-term outcomes and complications remain unknown. There is a lack of evidence of SI joint instability, fracture, or tumor. This patients records do not support a clinical justification for SI joint fusion. Thus, the requested right SI joint fusion 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: Overturned

Summary Reviewer 3


A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a single metastatic lesion in liver. SBRT has been used to treat primary liver cancer as well as metastatic lesions in liver. There are several clinical published studies to support SBRT for such clinical conditions (Lee, et al).  Moreover, the provider documents that the patient is not a candidate for radiofrequency ablation as the lesion is close to vessels. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 61-year-old female enrollee has requested reimbursement for magnetic resonance imaging (MRI) of the head performed on 1/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees head pain and traumatic injury. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. In this patients case, based on her age and symptoms, it would have been appropriate to perform cross-sectional imaging to exclude a significant brain injury.  The American College of Radiology noted although non-contrast head CT is normal in the majority of patients with minor or mild acute closed head injury, it remains the primary modality for detecting clinically relevant brain injuries in this patient population. Though non-contrast head CT has a high negative predictive value in triaging patients, this does not mean that a patient with a negative head CT does not have traumatic brain injury, and neurologically abnormal patients should be followed closely despite a negative head CT. MRI is not indicated as the initial imaging modality in the setting of minor or mild acute closed head injury. However, it may have a role in follow-up imaging. Of note, a small fresh subdural hematoma can occasionally be missed on MRI scans. There is a lack of support for an MRI in this setting, and in a general medical practice, a CT scan is appropriate. Thus, MRI of the head performed on 1/05/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were 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 


A 24-year-old female enrollee has requested reimbursement for intensive outpatient program services provided from 9/26/15 through 12/07/15. 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 the submitted documentation supports the medical necessity of the services at issue.  This patients eating disordered behaviors were intertwined with affective illness, psychosis and character pathology resulting in a complex episode of illness.  Based on the documentation provided, the patient remained ill and had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  During the disputed service, the patient was engaged in active treatment that included psychotherapy, nutritional counseling services, and psychiatric services including diagnostic evaluation and pharmacotherapy.  Despite these interventions, the patient continued to struggle with eating disordered behavior, poor self-esteem, mood symptoms and psychosis.  The record described an individual who had not optimized the skills needed to maintain weight and emotional stability in an outpatient based setting prior to the actual discharge date.  The patient remained at elevated risk for undue morbidity and admission to a higher level of care in the absence of intensive outpatient program level of care.   The disputed care was reasonably expected to improve her condition and prevent a more serious illness.  In sum, the intensive outpatient program services provided from 9/26/15 through 12/07/15 were 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: Upheld

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for inpatient skilled nursing facility care from 2/16/16 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 medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  On 2/14/16 and 2/15/16, she was requiring extensive assistance for her self-care.  She was not ambulating.  She had plateaued at requiring about moderate assistance for her transfers.  There is no documentation of any further, significant progress.  Overall, the patient had health issues and impairments which significantly increased the energy cost of her gait.  These deficits severely limited her functional progress with respect to self-care, transfers and ambulation.  Further rehabilitative care as of 2/16/16 and forward could have been provided at a less intensive level of care such as a custodial facility, or home care with custodial level assistance and community-based rehabilitation.  Given the patients substantial and chronic impairments and the limited gains achieved to date as of 2/16/16, it would not have been anticipated that she would have made further significant functional gains in a predictable and reasonable timeframe.  All told, inpatient skilled nursing facility care from 2/16/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, 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.