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

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for reduction mammaplasty performed on 12/03/15. 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.  The patient had chronic pain of the neck, back, and shoulders, as well as the breasts.  Her examination was consistent with significant asymmetric macromastia.  Conservative management included nonsteroidal anti-inflammatory medications.  Her degree of resection was consistent with a significant breast reduction.  The patients symptoms had significantly impacted her activities of daily living.  Multiple medical evaluations provided confirmatory evidence of these findings.  The records document a functional problem that was directly related to her significant macromastia.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  All told, reduction mammaplasty performed on 12/03/15 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 40-year-old female who was evaluated with a lactulose breath test on 7/31/19. The patient has requested authorization and coverage for Xifaxan. The Health Insurer has denied the request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. This patient has small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. This medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, fluoroquinolones, and penicillins. Results are sustained for several weeks after treatment. Therefore, Xifaxan is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 64-year-old female enrollee has requested reimbursement and prospective authorization and coverage for proton beam radiation. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found based on the submitted documentation, proton beam radiation is not likely to be more beneficial in this clinical scenario when compared with conventional treatment such as photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg beak, resulting in less dose to surrounding normal tissue and a lower integral dose (Shin, et al). The main use of proton therapy in the orbital region is in treating uveal melanomas too large for brachytherapy, where it has an accepted benefit over photons (Weber, et al). In the setting of a myelomatous orbital lesion, however, data is lacking due to the rarity of such a clinical scenario. As appropriate, the treating provider has submitted comparison plan data between protons and photon IMRT. While the doses to normal tissue are lower with protons versus IMRT, the IMRT doses are still well below accepted thresholds of toxicity. In other words, the protons are superior dosimetrically as would be expected, but there is unlikely to be any actually clinical benefit, as IMRT is already not expected to lead to any significant side effect. Based on the above, there is not expected to be any clinical benefit of using proton therapy over photon-based IMRT. As such, proton beam radiation was not and 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 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: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of an 11-year-old female enrollee has requested authorization and coverage for gene testing.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the patient is an ideal candidate for whole exome sequencing, given her multisystem disease, with short stature, intellectual disability, and renal anomalies (both structural and functional).  These multisystem findings increase the likelihood of an underlying single gene disorder which can be identified by whole exome sequencing.  The identification of a specific diagnosis in this patient may provide guidance for treatment of her renal anomalies and electrolyte abnormalities.  A unifying diagnosis may also provide insight into helpful treatments for growth failure.  Thus, the requested gene testing is likely to be superior over other methods of evaluating this patient.  Based upon the information set forth above, the requested services are 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 3 
 
A 39-year-old female enrollee has requested authorization and coverage for cervical transection 
and avulsion of extraspinal nerve. The Health Insurer has denied this request and reported that 
the requested services are investigational for the treatment of the enrollees medical condition. 
The physician reviewer found that the submitted records fail to demonstrate the superior efficacy 
of the requested services in this patients case. The records do not document behavior therapy 
despite significant research to support its use. Moreover, the research that is being listed by the 
requesting provider to support the procedure for the neck pain is a pilot study for the lumbar 
spine doing an endoscopic rhizotomy not a cervical transection and avulsion of extraspinal nerve. 
A review of the difference between studies is warranted. Leon and colleagues noted, The choice 
of the intervention for a pilot study should be based on theory, mechanism of action, a case 
series, or animal studies that justify a rationale for therapeutic effect...Despite the convention, 
pilot studies do not provide useful information regarding the population effect size because the 
estimates are quite crude owing to the small sample sizes. Basing a decision to proceed or 
terminate evaluation of a particular intervention on pilot data is perilous because there is a very 
good chance that the decision will be derived from false positive or false negative results. Per 
the authors, A pilot study is not a hypothesis testing study and therefore safety and efficacy are 
not  evaluated...In  summary,  pilot  studies  are  a  necessary  first  step  in  exploring  novel 
interventions and novel applications of interventions. Nothing submitted shows that cervical  transection and avulsion of extraspinal nerve has undergone the rigors of scientific research to 
move it from investigational research to standard of care. Nevertheless, all other treatments for 
neck pain have not been exhausted. Therefore, cervical transection and avulsion of extraspinal 
nerve is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 55-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 11/2/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the breast tomosynthesis performed on 11/2/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in the routine screening population. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the breast tomosynthesis performed on 11/2/15 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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 20-year-old male enrollee has requested reimbursement for the human T-lymphotropic virus (HTLV) testing performed on 4/25/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees sperm prior to banking. The physician reviewer found that sperm banking is regulated by the U.S. Food and Drug Administration (FDA). A committee opinion states that HTLV testing may be obtained at the discretion of the provider in the appropriate clinical setting. Although HTLV testing would benefit the recipient of the sperm and the embryo, the patient would not receive benefit. Thus, although the FDA recommends testing and the American Society Reproductive Medicine states it is optional, the HTLV testing in this circumstance was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 23-year-old female enrollee has requested reimbursement for the E0835 - RR continuous passive motion exercise device provided on 9/28/16. The Health Insurer has denied this request indicating that the device at issue is considered investigational for treatment of the enrollees status post right knee surgery. The physician reviewer found the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Fazalare and colleagues concluded that clinical evidence to support the use of CPM following knee cartilage defect surgery was lacking. The authors noted there is a need for well-conducted, high-level evidence studies to address this void in the medical literature. Similarly, Karnes and colleagues concluded that there is a paucity of clinical evidence to support broad implementation of CPM following cartilage restoration procedures. In addition, Gatewood and colleagues concluded that CPM was not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee range of motion. In this case, there is a lack of documentation showing complex regional pain syndrome, significant arthrofibrosis or tendon fibrosis, or inability to participate in active physical therapy to support the use of a CPM device over standard therapy. Therefore, the CPM exercise device provided on 9/28/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy in this clinical setting. Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 3/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees keratoconus. The physician reviewer found that based on the patients vision loss and progression, corneal collagen crosslinking was the most appropriate and effective treatment available. The medical evidence shows corneal collagen crosslinking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. In this clinical setting, there is a lack of treatment option available to slow or halt disease progression. Thus, corneal collagen crosslinking performed on 3/13/17 was likely to have been of greater benefit than other treatment options. 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: Overturned

Summary Reviewer 1

A 39-year-old male enrollee has requested authorization and coverage for autologous cultured chondrocyte and autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with chronic severe localized right knee pain and swelling. Functional limitations are noted in activities of daily living. He underwent right knee arthroscopy with chondroplasty of the medial femoral condyle, lateral femoral condyle, and trochlear groove on 1/25/18. Operative findings confirmed multiple full thickness chondral defects of the medial femoral condyle, lateral femoral condyle, and trochlear groove, approximately 2.25 cm2, 4 cm2, and 1.25 cm2 respectively. There were minimal degenerative changes in the surrounding articular cartilage, and intact and stable knee with normal joint spacing. He has failed long-term extensive conservative treatment. U.S. Food and Drug Administration (FDA) indications support the use of matrix autologous chondrocyte implantation (MACI) for the treatment of single or multiple symptomatic, full thickness cartilage defects of the knee. Current evidence-based medical literature supports the use of MACI as safe and effective, with better long-term outcomes as compared to microfracture surgery. In this case, the requested MACI would be supported for the treatment of this patients medical condition as safe and effective given his young age and multiple defects. Therefore, the requested autologous cultured chondrocyte and autologous chondrocyte implantation of the knee are likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 52-year-old female enrollee has requested reimbursement for the risk of ovarian malignancy algorithm (ROMA) test provided on 6/22/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees irregular menstrual bleeding and ovarian cyst. The physician reviewer found the American College of Obstetrics and Gynecology (ACOG) and the Society of Gynecologic Oncologists (SGO) have addressed the issue of the application and use of tumor markers in the evaluation of a pelvic/adnexal mass. The guidelines suggest the evaluation of symptomatic patients should include physical examination, possible transvaginal ultrasonography, and measurement of levels of the serum tumor marker CA-125. The underlying goals of management are to help direct patients suspected of having ovarian cancer. These findings also help gynecologic surgeons to comprehensive surgical staging and cyto-reductive surgery. However, the ACOG and SGO guidelines do not support the addition of HE-4 in this clinical setting. The patients presentation warrants surgical intervention with a preoperative evaluation by gynecologic oncology and did not require additional testing with HE-4 prior to this referral. Thus, the ROMA test provided on 6/22/15 was not likely to have yielded further information relevant to this patients management beyond that anticipated with standard CA-125 testing and proper clinical examination. 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 2

A 62-year-old male enrollee has requested reimbursement for laboratory services provided on 9/06/18. 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 this patient had an early stage melanoma with good prognostic features. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. In sum, laboratory services provided on 9/06/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. 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 the services at issue were antibody tests to specific serum proteins found in some patients with inflammatory bowel disease (IBD). The diagnosis of IBD is based on endoscopic, radiologic and histopathologic criteria. For several years, there has been a search for noninvasive markers that could replace part of this diagnostic process. Antibody markers, including microbial antibodies, autoantibodies and peptide antibodies, have been explored. At present, no single marker with qualities that are satisfactory for the diagnosis and treatment of IBD have been identified. The 2018 American College of Gastroenterology guidelines make the following statement: aSerologic markers of IBD - Routine use of serologic markers of IBD to establish the diagnosis of Crohn's disease is not indicated (
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 39-year-old male who is status post repair of left cleft lip and palate as a child. He does have a maxillofacial skeletal deformity and was evaluated by an oral surgeon and was found to have severe maxillary hypoplasia, mandibular hyperplasia, and missing tooth number 10 with an alveolar cleft in this area. His provider recommended orthognathic surgery with a Lefort 1 osteotomy, mandibular osteotomy and repair of his alveolar cleft. The patient has requested authorization and coverage for bone graft procedure; nasal, maxillary, or malar areas (includes obtaining graft) (CPT code 21210). The Health Insurer has denied this request indicating that the requested procedure is not medically necessary. Applying the parameters of care outlined by the American Association of Oral and Maxillofacial Surgeons (AAOMS), the proposed surgery is supported as medically necessary for the treatment of this patients medical condition. The provider reports that the patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics. The proposed procedure will result in improved musculoskeletal and dento-osseous relationships and improvement in mastication. The patient also has an alveolar cleft in the area of missing tooth number 10. Alveolar grafting of this site is indicated and is separate from the Lefort 1 procedure. The goals of this procedure are to provide adequate bone stock for his adjacent teeth and future dental replacement if needed, to establish a nasal skeletal base, and more ideal architecture in the area. All told, the requested bone graft procedure; nasal, maxillary, or malar areas (includes obtaining graft) (CPT code 21210) is medically necessary.  Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. 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 at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease. Given these risk factors and the severity of his infection and wounds, it was reasonable to admit him to a telemetry level of care for 24 hours. The initial 24 hours is sufficient time to check serial echocardiogram and cardiac enzymes and have a cardiology consultation. Furthermore, the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission, and after monitoring and serial enzymes/echocardiograms, he could have been treated at a lower level of care from 5/25/18 through 5/30/18. Therefore, inpatient stay at telemetry level of care provided from 5/23/18 through 5/24/18 was medically necessary for the treatment of this patient. The records fail to demonstrate the medical necessity of inpatient stay at telemetry level of care provided from 5/25/18 through 5/30/18.