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

Summary Reviewer 2


A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that the Anser IFX test was ordered to determine the cause for the patients possible loss of response to Remicade. However, management of ulcerative colitis using the Anser IFX has not been standardized, and recommendations for management based on test results have not been formed (Kornbluth and Sachar). In addition, the use of Anser IFX to direct treatment has not been clinically proven to improve patient outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not (Pariente, et al). Based on the clinical literature, the Anser IFX testing performed on 11/11/15 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 22-year-old female who was transferred by air ambulance from Swedish Medical Center (SMC) in Englewood, Colorado, to St. Josephs Hospital (SJH) in Phoenix, Arizona, on 9/26/19. The patient has a medical history significant for mild autism, attention deficit/hyperactivity disorder, and non-epileptic seizures. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. In order for air ambulance transportation to be medically necessary, specific criteria should be met. First, the patients condition must be such that any form of transportation other than ambulance would be medically contraindicated. Additionally, the patients condition must be such that time needed to transport by ground poses a threat to the patients survival. Also, the patient should be
transported to the nearest hospital with appropriate facilities for treatment, and there should be a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital must not have the required services and facilities to treat the patient.
In this patients case, she had nonepileptic seizures, or psychogenic nonepileptic spells. Psychogenic nonepileptic spells (PNES) or psychogenic nonepileptic episodes (PNEE) are terms used to describe events that appear to be epileptic seizures but in fact do not represent the manifestation of excessive synchronous cortical activity that defines epileptic seizures. They are not a variation of epilepsy, but are of psychiatric origin. These terms reinforce the idea that the events are not seizures of any type, and PNES is used as a synonym for pseudoseizures. Distinguishing PNES from epileptic seizures may be difficult at the bedside even to experienced observers. In theory, almost any recurrent behavior may represent epileptic seizures. The simultaneous utilization of video and EEG recordings are key to diagnosis, as was the case here. This patient had PNES, and she was under the care of a neurologist at SMC. Her condition was stable. Had there been a need for higher level of care, SJH in Phoenix, Arizona was not the closest facility capable of providing that care. Indeed, the patients family requested transport to Arizona so that the patients mother would be able to oversee her care and make medical decisions for the patient. Therefore, air ambulance transportation provided on 9/26/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for mental health residential treatment from 9/28/15 through 10/05/15 and prospective authorization and coverage for mental health residential treatment.  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 conditions.The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not suicidal or homicidal.  She denied self-harm urges.  She was not aggressive towards others, and her body weight was stable.  She had no medical or psychiatric conditions that would interfere with her ability to return to a lower level of care.  Her mother was supportive and actively participated in her care.  Per the medical records, the patient had improved and no longer required 24-hour medical or nursing supervision.  Therefore, mental health residential treatment from 9/28/15 through 10/05/15 and future mental health residential treatment 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient presented with chronic right wrist pain that interfered with his activities of daily living. He had a past medical history that included right distal radius fracture. Clinical examination findings were consistent with imaging evidence of right wrist post-traumatic arthritis of the radioscaphoid joint and STT joint with positive ulnar variance of 7.5 mm. He had failed to achieve sustained improvement with activity modification, medications, bracing and steroid injection. He underwent right wrist anterior and posterior interosseous neurectomies on 6/10/19 as an alternative to motion-limiting surgeries, including wrist fusion, proximal row carpectomy, and radioscapholunate arthrodesis. Current evidence-based medical literature supports the use of anterior and/or posterior interosseous neurectomies for the treatment of chronic wrist pain and to delay or avoid wrist fusion/reconstruction surgeries. There is adequate literature support for the use of this procedure as salvage prior to fusion. He had failed reasonable and/or comprehensive conservative treatment, and no additional conservative treatment would have been reasonably expected to improve his medical condition. Therefore, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested authorization and coverage for genioplasty sliding osteotomy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found osteoplastic genioplasty is a procedure that has been used for the treatment of sleep apnea with limited success. When the mandible is retrusive, usually a Class II malocclusion with an under projecting chin, an argument for sliding osteoplastic genioplasty would be a reasonable consideration. Theoretically, moving the chin forward, or anterior, will advance the tongue base forward and enlarge the hypopharyngeal airway. However, this is not the situation in this case. This patient has an overly projected chin with excessive vertical height and a poorly defined labiomental fold. The mandible is already over-projected. Thus, the osteoplastic genioplasty is being done to reduce the vertical height of the chin, not to advance the chin forward. This is done to improve the long face created by the excessive height of the mandible, and improve the aesthetics of the face by creating a more defined labiomental crease, but it will not improve the patients airway. There is an alternate indication for osteoplastic genioplasty. When performing maxillary advancement, bone grafts may be necessary to stabilize the maxilla. One source of bone is the mandible. If a bone graft is needed and this provides an adequate amount of bone, then a rib or cranial bone graft would not be needed. In this case, the surgeon did not include bone graft in the requested procedures. In sum, genioplasty sliding osteotomy in this clinical setting will not improve tongue position or add to improvement in the airway. As such, the requested services are not medically necessary for treatment of the patients medical condition. Thus, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. 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 there are few published data of cryotherapy devices with respect to health or functional outcomes in the setting of musculoskeletal conditions, including following knee surgery.  Hubbard and Denegar reported that, Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury.  There is some limited published literature related to hip and knee surgery. The medical literature does not indicate, however, that the use of these cooling devices is necessary in the postoperative period outside of the hospital, particularly when a patient is ambulatory. There is also insufficient high quality evidence that establishes that the use of cooling devices results in better outcomes over the use of topical ice pack application. All told, the Game Ready system provided on 9/10/15 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 56-year-old male enrollee who has requested reimbursement for Oncotype DX Prostate. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that The National Comprehensive Cancer Network (NCCN) guidelines define the low-risk group as patients with clinical stage T1 to T2a, Grade Group 1, and serum prostate-specific antigen (PSA) level less than 10 ng/mL. If the patients life expectancy is 10 years or more, initial treatment options include: 1) active surveillance (preferred); 2) external beam radiotherapy or brachytherapy; or 3) radical prostatectomy. This patient meets this criteria. Molecular tumor testing can be considered for these men for prognostic information independent of NCCN risk groups. There is sufficient support for the services at issue in this clinical setting. Therefore, Oncotype DX Prostate testing performed on 9/19/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 58-year-old female enrollee has requested reimbursement for blepharoplasty of the upper eyelid performed on 12/07/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The blepharoplasty was not medically necessary based on the lack of appropriate visual field studies and the lack of photographic evidence. In this setting, a suprathreshold static visual field test would have been appropriate rather than the full threshold test that was done in this case. In addition, the results provided were grayscale representations of the field, not the actual visual field test result. Thus, it is not possible to determine the degree from fixation where the absolute scotoma begins. There were no photographs to support the need for functional surgery. Therefore, upper eyelid blepharoplasty performed on 12/07/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found this patient received 36 treatments prior to the Health Insurers denial.  At this time, the literature on TMS is not clear on whether maintenance treatment is an evidence-based treatment.  The literature indicates that continued treatment can and should occur if an initial response to TMS is not apparent.  However, in this case, the patient did show an initial response to TMS treatment.   The records indicate that the patients symptoms had improved during the initial TMS treatment period.  Since the patient showed benefit from acute/initial TMS treatments and given the lack of evidence for maintenance TMS treatments, the superior effectiveness of the services at issue has not been established.  Based upon the information set forth above, the services at issue were not and 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 61-year-old female enrollee has requested reimbursement for neuropsychological testing performed on 12/28/14. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for treatment of the enrollees medical condition.The physician reviewer found that according to the American Academy of Clinical Neuropsychologys practice guidelines, distinctive features of neuropsychological evaluations and consultations in assessing brain function and dysfunction include the use of objective neuropsychological tests, systematic behavioral observations and interpretations of the findings based on knowledge of the neuropsychological manifestations of brain-related conditions. In this case, the symptom complex was consistent with affective illness and anxiety rather than a disease of neurocognition, such as delirium, dementia, frontotemporal degeneration, Parkinsons disease, prion disease, or Lewy body disease to name a few.  Psychosocially, the patient was relatively new to the community and involved in an emotionally convoluted relationship. In October 2014 she linked her memory issues and insomnia to her poorly controlled anxiety. During that appointment, the provider did not include specific examples of the memory decline or objective rating scales such as a Folstein Mini-Mental State Examination or a Montreal Cognitive Assessment. The patient was prescribed a trio of medications including temazepam, lamotrigine and quetiapine, each of which alone could cause cognitive dulling while the concomitant use of the three, particularly when combined with alcohol, commonly causes sedation. She did not follow through on the recommendation from the psychiatrist earlier in the year to reduce her quetiapine. Lastly, she was consuming alcohol and had reported previously drinking a bottle of wine nightly. During the most recent mental status examination from May 2015, the patients speech, thought process, insight and judgement were unimpaired, while her attention span and concentration were within normal limits. Neuropsychological testing is not medically necessary to diagnose anxiety or affective disorders. Further, the patient had not followed through with the recommended medication reductions and she continued to consume alcohol while facing several external stressors. Finally, the patient did not have evidence of a neurocognitive disorder while her most recent mental status examination was normal. In sum, the documentation submitted for review does not support the medically necessity for the neuropsychological testing performed on 12/28/14.Therefore, the testing at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 23-year-old female enrollee has requested reimbursement for realignment of the right jaw joint (condylotomy) performed on 4/29/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees temporomandibular joint pain. The physician reviewer there is sufficient support for the services at issue in this clinical setting.  This patient has been diagnosed with temporomandibular joint disease and was treated non-surgically.  However, this failed to resolve her symptoms.  The records document an internal derangement of her right temporomandibular joint with persistent symptoms.  The modified condylotomy is a well-known procedure with a high success rate.  The current medical evidence supports the services at issue in this clinical setting.  All told, realignment of the right jaw joint (condylotomy) performed on 4/29/16 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.  The physician reviewer found the patient is a 34-year-old male who has been diagnosed with persistent Lyme disease. He had a positive IgM Western blot for Lyme with a negative IgG western blot for Lyme on 3/28/13. There is no further laboratory testing submitted to support a diagnosis of secondary, tertiary or chronic Lyme or neuroborreliosis. An office visit note dated 9/9/15 indicates that the patient reports doing better in general and marked improvement with starting Bicillin. The patient reports improved strength, less tremor/shaking and improvement in cognitive function. The assessments are listed as Lyme disease, anxiety state, attention or concentration deficit, malaise, fatigue, myalgia and myositis, headache, bartonellosis, candidiasis of mouth and disturbance of skin sensation. In the patients appeal letter, he states that has been using Bicillin L-A since July 2015 and has improved shaking and vibrating, more energy, less tingling, trouble walking, memory and nerve problems and more. The patient has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request as investigational. 

Based on the documentation submitted for review, there is a lack of evidence demonstrating the patient has chronic Lyme disease. The laboratory data shows that he may have had acute or early Lyme in September 2013, but no evidence of ongoing infection is submitted. In the absence of evidence of ongoing infection with Borrelia or any other tick born disease, antibiotic treatment is less likely to be of benefit. In addition, the Infectious Diseases Society of America (IDSA) guidelines report that long term antibiotic treatment does not improve the outcome in patients suffering from Lyme, post Lyme or chronic Lyme. Thus, continued use of antibiotics beyond a month without evidence of ongoing infection cannot be justified. Given the above, Bicillin L-A 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 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 1


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 the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The study by Schmidt and colleagues compared the specificity and sensitivity of a hand-held nerve conduction study device for the detection of lumbosacral radiculopathy with a standard electrodiagnostic study. The authors noted correlation between the electrodiagnostic findings and the automated hand-held surface testing in only a small number of the patients studied. The authors concluded that it was unlikely that larger study numbers would have increased specificity to acceptable levels. In sum, the services at issue 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.