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

Summary Reviewer 3

A 28-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma and shortness of breath. The physician reviewer found that bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees centigrade. There are three bronchoscopic procedures. The first treats the right lower lobe, the second the left lower lobe, and the third bronchoscopic procedure is for both upper lobes. The procedures are scheduled three weeks apart. This patients provider states the patient has a progressive decrease in the quality of life, but there is a lack of documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. Thus, the requested bronchial thermoplasty is not likely to provide this patient with an improved health outcome when compared with standard alternatives. Based upon the information set forth above, the requested procedure 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 33-year-old female who had preconception genetic carrier screening with her spouse.Both were found to be carriers of a cystic fibrosis (CF) gene mutation. The physician reviewer found that the basis of screening patients pre-conception for CF among other conditions is to provide actionable information to avoid having an affected child. This was done in this case, and provided the impetus to pursue what is currently the best option to avoid having a child with CF. In vitro fertilization with prenatal genetic screening essentially avoids the risk of having to terminate an affected pregnancy, or having a child with a serious lifelong and ultimately fatal condition. The American College of Obstetricians and Gynecologists (ACOG) Committee Opinion on pregnancy counseling notes, Couples at risk of having children with specific genetic diseases can be counseled about the disease inheritance and course and offered referral for potential interventions, such as preimplantation genetic testing. It recommends screening of all women who are planning a pregnancy for this reason. The ACOG Committee Opinion on Identification and Referral of Maternal Genetic Conditions in Pregnancy states, Patients with established causative mutations for a genetic condition, and who desire prenatal genetic testing, should be offered preimplantation genetic testing with in vitro fertilization by a reproductive endocrinologist. There is sufficient support for the requested services in this clinical setting. Therefore, the requested embryo transfer is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a 13-year-old male enrollee has requested reimbursement for balloon sinus ostial dilation performed on 10/28/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic sinus problems. The physician reviewer found there is sufficient support for the services at issue in this patients case. The indication for balloon sinuplasty is chronic sinusitis refractory to maximal medical treatment.  Chronic rhinosinusitis was documented in this patient. There was documentation that he was treated with maximal medical therapy prior to the computed tomography (CT) scan. He has been treated with multiple courses of antibiotics and with adenoidectomy, which is the first-line treatment for sinusitis in pediatric patients. Balloon sinuplasty is an effective therapy for chronic sinusitis patients and for pediatric patients.  In sum, balloon sinus ostial dilation performed on 10/28/15 was likely to have been more efficacious 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 38-year-old female with a history of chronic left hip pain in the groin related to CAM type femoroacetabular impingement, with a small pincer and associated tear of the anterior-superior labrum. The patient has requested reimbursement for hip arthroscopy performed on 12/03/19. 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 there is sufficient support for the services at issue in this clinical setting. Femoroacetabular impingement is a common condition among young adults. Griffin and colleagues compared physical therapy and surgery for management of this condition. Among 348 participants, 171 participants were treated with hip arthroscopy and 177 were treated with hip physical therapy. Both treatments improved the quality of life. However, hip arthroscopy resulted in greater improvement than physical therapy. In this patientas case, the procedures performed at the time of hip arthroscopy were appropriate and are known to be beneficial. These included arthroscopic surgery on her left hip consisting of acetabular rim trimming, repair of the labral tear, femoral osteochondroplasty, and capsular plication. The operative report describes the deformity that was corrected. Physical therapy was not helping at three months, and surgery was medically indicated. Therefore, hip arthroscopy performed on 12/03/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on
1/27/20. 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 Guardant360 is a multigene assay done from circulating DNA in blood. It is capable of reliably
detecting tumor-related genetic mutations and molecular abnormalities. The issue is whether such
an assay can direct therapy to a clinically beneficial and reliable degree. Thus far, there has been
a lack of convincing evidence that the Guardant360 assay is likely to be clinically beneficial in the
treatment of breast cancer. Finding a mutation does not guarantee that a treatment directed at that
atargeta will be successful. The likelihood of benefit from using therapy based on genomic assay
is small. Therefore, genetic testing performed on 1/27/20 was not likely to have been more
beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 27-year-old female with a history of lymphedema of the right lower extremity. The 
patient developed lymphedema of the right lower extremity in 2017, which spread to her calf and 
thigh by 2018. The provider recommended treatment with lymphaticovenous anastomosis (LVA) 
and vascularized lymph node transfer (VLNT) surgeries with inpatient hospital stay. The Health 
Insurer has denied the requested inpatient hospital stay associated with the approved LVA as not 
medically necessary for treatment of the patients medical condition. This denial is the subject of 
this appeal and determination. The physician reviewer found that the current medical literature 
supports the use of LVA for treatment of patients with lymphedema. While LVA requires less 
hospitalization than VLNT, there is a lack of medical literature suggesting outpatient treatment is 
adequate for patients undergoing treatment with LVA. In a study by Cha and colleagues involving 
patients with advanced lymphedema that underwent LVA, the authors noted that, The patients 
were discharged on postoperative day 3 or 4, and they received education on proper compression 
therapy at discharge. In another study, Gallagher and colleagues reported that, The complication 
rate of LVA is low. These procedures can often be performed under local anesthesia, and there is 
minimal length of stay. In this case, the patient has a history of lymphedema of the right lower 
extremity and has been recommended treatment with LVA and VLNT surgeries. The records 
document that the patient has failed to improve despite treatment with SAPL of the right lower 
extremity, compression garments, and ablation procedures. Based on the medical literature, the 
requested inpatient hospital stay associated with approved LVA surgery is medically necessary for 
treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 25-year-old male enrollee has requested reimbursement for quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeAaas medical condition. The physician reviewer found that standard of care for major depressive disorder involves treatment with different classes of antidepressants, such as selective serotonin reuptake inhibitors, serotoninAaanorepinephrine reuptake inhibitors, bupropion, mirtazapine or newer generation antidepressants. After a patient fails antidepressant trials from multiple classes, the standard of care is to then add an adjunctive medication, such as aripiprazole, quetiapine, risperidone, or lithium. This patient tried only one antidepressant. Psychotherapy (specifically cognitive behavioral therapy) is also highly recommended as a first-line treatment for depression as well as anxiety disorder, as well as the combination of pharmacotherapy and psychotherapy. There is no documentation provided that the patient failed psychotherapy. Given that there is no documentation (Patient Health Questionnaire 9 other other rating scores) of the patientAaas improvement before and after neurofeedback treatment, and this treatment has very little evidence showing benefit in this specific condition (major depression), standard therapy (adjunctive medications, CBT, other psychotherapy, ECT) should have been tried. Therefore, quantitative EEG (brain mapping) performed from 7/02/20 through 8/25/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 56-year-old male enrollee has requested reimbursement for the Cologuard test provided on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers (KRAS mutations, NDRG4, and BMP3 methylation) and a non-DNA immunochemical assay for human hemoglobin (e.g. FIT). Given the low sensitivity of Cologuard in detecting adenomas, the assay is not likely to be more beneficial for evaluation of the patients medical condition than the gold standard colonoscopy. Further, the records submitted for review do not support that the patient is contraindicated to more effective screening strategies. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
A 35-year-old female enrollee has requested reimbursement for the three-dimensional (3D) mammogram provided on 10/31/16. The Health Insurer has denied this request indicating that the service at issue is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found that the 3D mammogram provided on 10/31/16 was 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 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 documentation submitted for review and medical literature cited above, 3D mammogram 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 service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. 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 current medical evidence has not established the superior effectiveness of the services at issue. Lipoprotein particles, which carry cholesterol and triglycerides, are comprised in part of apolipoproteins. Although some have proposed that the measurement of lipoproteins or apolipoproteins may be useful in some patients, the 2010 American College of Cardiology Foundation/American Heart Association guideline for assessment of cardiovascular risk in asymptomatic adults does not recommend the use of these tests for cardiovascular risk assessment in asymptomatic adults. Therefore, advanced lipoprotein testing performed on 10/19/20 was not likely to have been more beneficial than other available standard methods of evaluation.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 The patient is a 62-year-old asymptomatic female who was evaluated with screening mammogram and digital breast tomosynthesis on 3/31/16. The patient reported a positive family history for breast cancer. The patient also felt a lump in her right breast. She had bilateral mammography including breast tomosynthesis which revealed vague density requiring further ultrasound evaluation. The studies showed no mass. The patient has requested reimbursement for the breast tomosynthesis portion of her examination. The Health Insurer has denied reimbursement for digital breast tomosynthesis performed on 3/31/16.  Per the Health Insurer, the service at issue was investigational for the evaluation of this patient. There is evidenced base support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 50-year-old female enrollee has requested reimbursement for laboratory services (82306) provided on 6/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who has a history of anxiety, depression, insomnia and attention deficit disorder. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient has a history of depression, anxiety, attention deficit disorder and insomnia. The psychiatric literature does not support the use of testing for vitamin D or supplementation of vitamin D for psychiatric conditions. It is not clear that the patient has had cognitive behavioral therapy (CBT) for her major depressive disorder or anxiety disorder diagnoses.  It is not clear that the patient has tried other forms of psychotherapy that have been shown to be effective for her diagnoses. CBT is a first-line treatment for the patients conditions. Vitamin D testing was not an evidence-based treatment approach in this patients case. All told, laboratory services (82306) provided on 6/26/18 were 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 

The patient is a 43-year-old male who has been diagnosed with generalized anxiety disorder with panic attacks. In a letter dated 1/07/19, the patient reported that he was experiencing a panic attack when he asked his colleague to call 911. The physician reviewer found that per the submitted documentation, the patient believed that he may have been experiencing a myocardial infarction due to his symptoms. He requested an immediate emergency evaluation due to his symptoms, including loss of feeling in his extremities. Based on the records, a prudent layperson would have sought immediate medical attention if given a similar symptom presentation.   The medical literature indicates that patients who have anxiety or panic attacks often have physical symptoms that may mimic a serious medical problem, such as a myocardial infarction. Emergency medical evaluation would be requested and desired by a prudent layperson who believed they were experiencing a myocardial infarction. Therefore, A0998 (ambulance response and treatment, no transport) provided on 10/27/18 were emergency services.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 21-year-old female enrollee has requested reimbursement for knee arthroscopy synovectomy performed on 12/20/17. 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 Schindler concluded that arthroscopic excision of the entire plical fold becomes indicated in recalcitrant cases and once a plica has undergone irrevocable morphological changes. The procedure carries low morbidity, and results are universally good, especially if the plica is the sole pathology. Hufeland and colleagues concluded that arthroscopic resection of a symptomatic medial plica provides excellent clinical results in young patients. This patient presented on 12/20/17 with recalcitrant right knee pain and prominent medial synovial plica. She had failed to improve despite conservative treatment. She underwent right knee arthroscopy with medial synovial plicectomy excision, debridement and synovectomy on 12/20/17. Current evidence-based medical guidelines support arthroscopic surgical intervention in this clinical scenario for synovial plica resection/synovectomy. Increased synovial hypertrophy is typically associated with multicompartmental pathology, as in this case. Therefore, knee arthroscopy synovectomy performed on 12/20/17 was likely to have been more beneficial than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of a 10-month-old female enrollee has requested authorization and coverage for lansoprazole. 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 that Lansoprazole may be indicated in select cases, such as patients with esophagitis and postoperative esophageal dysmotility. The article by Hassall and colleagues noted the presumed safety and efficacy of proton pump inhibitor therapy in this age-group, but this was in the setting of defined esophagitis. It is difficult to label an infant as having an acid-related disease based on clinical assessment alone. The trend has shifted away from routine use of prolonged acid suppression in otherwise healthy infants. There may be a role for empiric use in the setting of feeding aversions or poor weight gain, but neither of those situations were demonstrated here. Thus, lansoprazole is not likely to be superior over other treatment options.