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

Summary Reviewer 

The patient is a 54-year-old male who has been diagnosed with alcohol use disorder, elevated liver function testing, atrial fibrillation, hypertension and rheumatoid arthritis. The patient has requested reimbursement for substance abuse residential treatment from 8/01/19 through 8/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that per American Society of Addiction Medicine criteria, this patient meets Level 3.5 criteria for clinically managed high-intensity residential services. With regards to dimension 1, acute intoxication/withdrawal potential, the patient was drinking heavily and reported feeling withdrawal symptoms. In terms of dimension 2, biomedical conditions and complications, the patient was on blood thinners, making potential falls while intoxicated fatal. With regards to dimension 3, emotional, behavioral or cognitive conditions, the patient had anxiety symptoms. In terms of dimension 4, readiness to change, the patient was willing to change but was ambivalent. With regards to dimension 5, relapse, continued use or continued problem potential, the patient had a long history of use without long periods of sobriety. In terms of dimension 6, recovery environment, the patients environment was supportive but lacked structure. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, substance abuse residential treatment from 8/01/19 through 8/04/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
 
A 22-year-old male enrollee has requested reimbursement for substance use outpatient services provided from 10/25/16 through 11/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. Routine outpatient treatment is standard of care for patients with amphetamine use disorder. From 10/25/16 through 11/10/16, the patient was treated using EMDR therapy. EMDR is evidenced based practice in treating past psychological trauma which is a common comorbid condition for those with substance use disorders. Treatment with EMDR therapy in an outpatient setting is one of the least restrictive methods of delivering psychiatric care. This patient required treatment for his amphetamine disorder. As such, the documentation provided as well as the medical literature, support the services at issue. Therefore, in this patients case, substance use outpatient services provided from 10/25/16 through 11/10/16 were medically necessary for the treatment of this patient.  Based on the reasons stated above, 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: Overturned

Summary Reviewer 1


A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 8/20/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that due to the advantages tomosynthesis brings to radiologists in the interpretation of digital mammography, the American College of Radiology (ACR) statement on breast tomosynthesis has urged the technique be removed from the investigational category. The advantages relate to the separation of dense glandular tissue from underlying architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) mammographic views was likely of more benefit to the patient than had the study been done with 2D imaging alone. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 51-year-old male enrollee has requested reimbursement for a coronary computed tomography (CT) calcium scan provided on 3/15/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees hyperlipidemia. The physician reviewer found that use of the coronary CT calcium score has not been recommended as Class I indication by the American College of Cardiology (ACC). The ACC guidelines state that for asymptomatic patients, coronary calcium score is reasonable in the intermediate risk group but it has not achieved class I recommendation supporting routine use for all patients regardless of risk factors. Currently, the standard approach for risk stratification does not include coronary CT calcium scan in this clinical setting. Thus, the coronary CT calcium scan provided on 3/15/18 was not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, 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 

The patient is a 63-year-old female with a history of hypertrophic cardiomyopathy, non-sustained ventricular tachycardia. The patient has requested reimbursement for telemetry level of care provided from 3/13/20 through 3/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that this patient had severe hypertrophic cardiomyopathy and known non-sustained ventricular tachycardia. At baseline, this patient is at a significantly higher risk for life threatening rhythm disturbances. Postoperatively, with the attendant injury and edema to the septal myocardium along with the marked electrolyte shifts of the postoperative period, she would be at even higher risk for life threatening rhythm disturbances. Maintaining her in a cardiac telemetry monitored situation was medically necessary given the underlying arrhythmic substrate of her cardiomyopathy, coupled with the various surgical stresses. She had documented ventricular tachycardia postoperatively noted on the telemetry monitor and atrial fibrillation with rapid ventricular response, both of which required immediate treatment in the perioperative period. Given her elevated risk of a life threatening arrhythmia, she was also not considered for discharge until an AICD had been implanted, making the necessity of postoperative cardiac monitoring all the more important. Therefore, telemetry level of care provided from 3/13/20 through 3/16/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 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 behavioral health conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Documents critical to the review, such as a psychiatric assessment, interpretative summary, serial progress notes, longitudinal history of the illness burden and outcomes of specific evidence-based psychotherapies and non-pharmacologic interventions, were not presented.  The information provided, including the patients lengthy course of treatment with mood stabilizing and antipsychotic medications and poor tolerability of antidepressants, strongly suggests bipolar depression rather than a unilateral mood disorder and does not detail the influence of the patients psychiatric comorbid conditions.  Considering transcranial magnetic stimulation is indicated for the acute phase treatment of major depressive disorder at this time, and the safety and effectiveness of transcranial magnetic stimulation therapy has not been established for other psychiatric disorders, the medical necessity of the services at issue cannot be established.  All told, transcranial magnetic stimulation therapy from 6/30/16 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement for the anesthesia services provided on 11/1/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees gastritis.   The physician reviewer found that the patient is an ASA status II, non-emergent patient who underwent evaluation with an upper endoscopy with MAC services. The records provided for review document the patients medical history includes low blood pressure. Sohn and Ryu concluded that many procedures in and outside of the operating room, including eye surgery, otolaryngologic surgery, cardiovascular procedures, pain procedures, and endoscopy are performed with MAC to increase patient and operator satisfaction. However, a history of low blood pressure is not a medically indicated condition to warrant MAC for an upper endoscopy. All told, the anesthesia services provided on 11/1/16 were not medically necessary for evaluation of this patients gastritis.  Based on the foregoing discussion, 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: Upheld

Summary Reviewer 

The patient is a 63-year-old female who was diagnosed with metastatic colon cancer in December 2017. She was treated with surgery, but chemotherapy was delayed due to a patellar fracture, and she developed carcinomatosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Kuter suggests that reduction in chemotherapy dose/frequency or alteration of regimen and platelet transfusions are the standard of care. Thrombopoietin receptor agonists such as eltrombopag are an alternate in patients who cannot be supported with transfusion and for whom reduction in dose/frequency would negatively impact survival. In this patients case, there is no indication that she could not be supported with either dose/regimen change or platelet transfusions.
Of note, the patients platelets are above the threshold for treatment with oxaliplatin, which is part of FOLFOX. Treatment with oxaliplatin only requires a platelet count of 75,000, which the patient has had. Therefore, Promacta 50 mg tablets are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that according to the documentation submitted for review, this patient is unable to tolerate prep for a colonoscopy due to the triggering of migraines. The patient underwent stool-based DNA and fecal occult hemoglobin to screen for colon cancer. These tests are considered an acceptable standard of care for colon cancer screening in average risk individuals. In addition, these tests will not trigger adverse symptoms and would detect a cancerous lesion and possibly avoid a colonoscopy. Given the above, the colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15 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 2


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15.  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 services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the medical literature cited above, the use of breast tomosynthesis 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: Upheld

Summary Reviewer 3

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network (NCCN) guidelines states that 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. The results of this testing was not likely to have altered treatment and surveillance recommendations. In sum, the superior effectiveness of gene expression profiling performed on 5/14/17 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 50-year-old female enrollee has requested authorization and coverage for interstitial radiation 
source application, complex, includes supervision, handling, loading of radiation source, when 
performed. The Health Insurer has denied this request and reported that the requested service 
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The 
physician reviewer found that Y90 radioembolization has been shown to be an effective targeted 
treatment  for  tumors  of  the  liver.  In  this  case,  an  applicator  is  used  to  directly  infuse 
microspheres of Y90 into the tumors. These microspheres are delivered through arteries that 
feed directly into the tumor and emit a radionuclide which kills cancer cells. This allows for a very 
targeted dose to be delivered. Liver tissue is highly radiosensitive so targeted therapies are 
critical to ensure lower liver toxicity. At present, Y90 therapy has demonstrated a favorable 
therapeutic ratio with improved overall survival outcomes and low toxicity rates. While there is 
a lack of prospective, randomized trials directly comparing Y90 and other similar targeted liver 
therapies, Y90 has continued to demonstrate a good safety profile. Tsang and colleagues report 
that Y-90 was well-tolerated in patients with metastatic liver-dominant neuroendocrine tumors. 
In phase 3 data combining Y90 therapy with systemic therapy in the setting liver metastases, 
Chauhan and colleagues reported that the addition of the Y90 therapy showed significantly 
longer progression-free survival and hepatic progression-free survival. Current medical literature 
corroborates the low toxicity and improved overall survival data with Y90 therapy. Overall, Y90 
has a track record of improving overall survival in the setting of liver metastases with a fairly low 
toxicity  profile.  Given  the  disease  burden  seen  within  this  patients  liver,  directed  Y90 
radioembolization with targeting of the liver metastases will likely be more beneficial than other 
standard forms of treatment in this setting. Therefore, interstitial radiation source application, 
complex, includes supervision, handling, loading of radiation source, when performed, is likely to 
be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 34-year-old female enrollee has requested reimbursement for homocysteine testing performed on 6/10/20 and 9/23/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrollees condition than any available standard therapy. The physician reviewer found that the current medical evidence does not support the services at issue in this clinical setting. The records do not document a medical indication for the services at issue. It has no pertinent clinical usefulness, especially in a patient with normal thyroid function and normal hemoglobin levels. The records do not indicate that the patient was on immunosuppressive medications. The literature does not support the use of homocysteine level in this clinical scenario. Therefore, homocysteine testing performed on 6/10/20 and 9/23/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that the request for POEM and associated inpatient admission is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. POEM is a minimally invasive treatment for achalasia, and there is sufficient peer reviewed data to substantiate its safety and efficacy. Teitelbaum and colleagues studied patients who underwent POEM for treatment of esophageal motility orders. The authors reported that POEM resulted in successful palliation of symptoms in the majority of patients after five years. In this case, the patient is a good candidate for this minimally invasive therapy. POEM obviates the need for operative exploration and dealing with expected adhesive disease from her transplant. Therefore, 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

The patient is a 47-year-old female with a history of bed confinement with upper and lower extremity weakness and contractures with pain that prevents movement. On 11/30/16, the enrollee was transferred from Kindred Los Angeles Hospital to Cedars-Sinai Medical Center for follow-up appointment for cerebral arteriovenous shunt. The enrollee was monitored en route. The patient has requested reimbursement for the non-emergency ambulance service provided on 11/30/16. The Health Insurer has denied this request indicating that the service at issue was not medically necessary. This patients records do not include any clinical justification for the ambulance service provided on 11/30/16. The patient is bedridden but does not require medical transportation. The documentation suggests that the use of the ambulance was provided for patient convenience. Accordingly, the non-emergency ambulance service provided on 11/30/16 was not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the service at issue was 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

The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that CMA is recommended by the American College of Medical Genetics as a first-line test for patients with autism spectrum disorders. The yield of CMA in patients with autism spectrum disorders is estimated to be around 10%. While findings on CMA may not alter treatment of the features associated with autism spectrum disorders in all patients, CMA has become the standard of care in this clinical setting. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, some copy number variations have also been associated with neuropsychological treatments or medications that have been shown to be more efficacious in this patient population. Additionally, copy number variations on CMA may inform about possible other complications and medical risks. All told, the FirstStep PLUS test provided on 11/23/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing 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.