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

Summary Reviewer 3 
 
A 60-year-old female enrollee has requested authorization and coverage for percutaneous or 
endoscopic spinal surgery. 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 a clear majority of current quality studies support MILD in 
appropriately indicated patients. Jain and colleagues performed a review of 13 clinical studies, 
including  two  randomized  controlled  trials.  The  authors  noted  statistically  significant 
improvement in pain and mobility, and superiority of MILD versus epidural steroid injections. In  the multicenter study by Chopko, patients demonstrated a statistically significant reduction of pain 
and statistically significant improvement in physical function and mobility from baseline through 
two years. A randomized controlled clinical study by Staats and colleagues showed excellent 
durability of the MILD procedure out to two years. All efficacy outcomes achieved significant 
improvement from baseline to all follow-up intervals through two years. There was no evidence 
of spinal instability at two years after the MILD procedure. According to the authors, MILD 
demonstrated lower re-operation rates, less morbidity and greater safety when compared to the 
broad range of lumbar spine interventions, including spacers, surgical decompression, and spinal 
fusion. In a retrospective study by Mekhail, and colleagues, subjects experienced statistically 
significant pain relief and reduction of opioid medications utilization at 3, 6, and 12 months 
compared to baseline. MILD was also shown to be durable with only 9 out of 75 patients requiring 
lumbar surgical decompression during the five-year follow-up period. MILD has been shown to 
be a safe and effective procedure. There is sufficient support for the requested services in this 
clinical  setting.  Therefore,  percutaneous  or  endoscopic  spinal  surgery  is  likely  to  be  more 
beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


The parent of a 17-year-old male enrollee has requested reimbursement for intravenous treatment with antibiotics for Lyme disease from August 2015 through November 2015. 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 this patient has a history of a fatiguing illness.  The etiology is not clear although one pediatrician did make a diagnosis of chronic fatigue syndrome.  The patient was subsequently given a clinical diagnosis of Lyme disease.  He was prescribed oral and parenteral antibiotics in the absence of any evidence of an infection.  The period of therapy was also extended past the recommended duration.  It is well-established that a maximum of 28 days is needed to treat late Lyme disease.  Thus, intravenous treatment with antibiotics for Lyme disease from August 2015 through November 2015 was not likely to have been of greater benefit than other treatment options.  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: Overturned

Summary Reviewer 1

The parent of an eight-year-old male enrollee has requested reimbursement for FirstStep Dx Plus testing performed on 5/28/14.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the testing at issue was likely to be more effective for this patient than other available treatment options. Chromosomal microarray analysis (CMA) is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with ASD (Manning and Hudgins). The yield of CMA in patients with ASD is estimated to be around 10 percent. While findings on CMA may not alter treatment of ASD features themselves in all patients, CMA has become the standard of care for diagnosis in patients with ASD. Increasing numbers of patients with ASD have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ASD due to that underlying cause. Additionally, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. For the reasons provided, FirstStep Dx Plus testing performed on 5/28/14 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 14-year-old female who presented to her provider on 3/2/23. The records noted a 
diagnosis of absence epilepsy and intractable epilepsy. The physician reviewer found that at issue is 
whether the requested rufinamide 400 mg tablet #180/30 days is medically necessary for the treatment 
of this patient. The submitted documentation supports the medical necessity of the requested 
medication. In this case, the patient has a history of absence epilepsy that has proven to be refractory to 
conventional first-line therapies. The records note that Depakote therapy was associated with 
pancreatitis, which precludes a retrial.  As newer anti-epileptic drugs have emerged, with different 
mechanisms of action, epileptologists are faced with balancing best practices based on available drug 
trials and emerging clinical experience with side effects. Besag and colleagues note that evidence from 
randomized, double-blind, placebo-controlled trials supports the use of rufinamide as adjunct treatment 
for drop seizures for patients with Lennox-Gastaut syndrome (LGS). While the patient in this case does 
not have a diagnosis of LGS, the records document an associated epilepsy which has left her with a poor 
quality of life and limited choices. Panebianco and colleagues report that for people with drug-resistant 
focal epilepsy, rufinamide when used as an add-on treatment is effective in reducing seizure frequency. 
In this clinical setting, while not without its own host of side effects, given that rufinamide may reduce 
this patients seizure burden and provide her with a reasonable quality of life, the requested medication 
is medically indicated. Therefore, rufinamide 400 mg tablet #180/30 days is medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a nine-year-old female enrollee has requested reimbursement for a dental expander. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees dental condition. The physician reviewer found There is a lack of support for the services at issue in this clinical setting.  The documentation indicates that the patient was treated with a palatal expander due to a narrow upper arch with crowding and description of a unilateral crossbite.  While the handicapping labio-lingual deviation index was 27, the method of scoring was questionable.  There is no documentation provided to corroborate this score, and the scoring does not appear congruous with the limited case notes provided.  The records included no preoperative work-up other than the handicapping labio-lingual deviation index score, which may have been calculated retrospectively.  The literature does not have a consensus on whether interceptive treatment is always necessary, relying on variables such as whether the crossbite observed is unilateral or bilateral, whether that noted is a true unilateral crossbite or caused by a variation in the path of closing, and the degree of crossbite.  The submitted records fail to demonstrate the medically necessity of the services at issue in this patients case.  All told, the dental expander was not medically indicated for the treatment of this patient.  Therefore, the services at issue were 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 49-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of atrial septal defect. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found the request for closure of PFO is not likely to be more effective for this patient than other available options. Studies to date have not shown a clear benefit of transcatheter closure of PFO compared to standard medical therapy. Observational studies from a single institution, non-randomized, suggest some benefit (Inglessis, et al). In sum, there is a lack of sufficient data to support the request for percutaneous transcatheter closure of atrial septal defect for this patient at this patient at this time. Based upon the information set forth above, the services at issue 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 1

A 37-year-old female enrollee has requested reimbursement for gene testing performed on 1/19/15.  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 while fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, gene testing performed on 1/19/15 was likely to have been superior over other methods of evaluation.  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: Overturned

Summary Reviewer 

The patient is a 57-year-old male who presented to the emergency department of Mercy Medical Center in Redding, California with complaints of nausea, vomiting, decreased oral intake and epigastric abdominal pain radiating to the back.  The patient has requested reimbursement for air ambulance transport provided on 10/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that in order for air medical transport to be medically necessary, all medical necessity criteria must be met. These criteria include: the patientas condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient. Per the submitted documentation, this patient required an ERCP. Mercy Medical Center did not have gastroenterology services available to perform an ERCP. The documentation noted that California Pacific Medical Center a Van Ness was the closest facility with available gastrointestinal services. Time for ground transportation was at minimum 3 hours and 37 minute via a toll road. Generally, ground transport times greater than 30 minutes would justify the initiation of air transport. Transport by air took 1 hour and 28 minutes. There is sufficient support for air ambulance transport in this case. Therefore, air ambulance transport provided on 10/16/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 59-year-old female who is diagnosed with uterine leiomyosarcoma. She was initially diagnosed at age 43 with stage I disease that recurred 15 years later. She was treated with doxorubicin and an anti-PDGFA antibody. A sample of the tumor was submitted for FoundationOne mutational analysis. The patient has requested reimbursement for the FoundationOne test performed on 11/14/16. The Health Insurer has denied this requested and reported that the services at issue were investigational for the evaluation of this patients medical condition. The FoundationOne test is Clinical Laboratory Improvement Amendments (CLIA) approved for use on clinical specimens. It is a next generation test that analyzes for mutations or rearrangements in approximately 400 oncogenes and tumor suppressor genes. A study by Von Hoff and colleagues involved 86 patients where the progression free survival (PFS) on the regimen selected by molecular profiling was compared to the PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has very significant results for patients with stage IV tumors.  There are many parallels in the molecular genetics between soft tissue sarcomas and hematologic malignancies. For example, dermatofibrosis protuberans is characterized by recurrent translocation involving PDGFB, which may be targeted by imatinib.  There is support in the medical literature for the use of genetic testing to identify mutations that may be amenable to targeted therapies. As such, the FoundationOne test performed on 11/14/16 was likely to have been more effective than the standard techniques available for evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for optical endomicroscopy performed on 5/30/18. 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 there is some support for the services at issue in this clinical setting. Eluri and colleagues noted confocal laser endomicroscopy (CLE) can increase the yield of dysplasia detection with good accuracy compared with random biopsies. Wang and colleagues noted the use of CLE as a complementary tool during the endoscopic evaluation of Barretts esophagus was strongly supported by the panelists.  In this case, the finding of nodule with dysplasia warranted resection rather than ablation as performed for the remaining Barretts esophagus. For these reasons, optical endomicroscopy performed on 5/30/18 was likely to have been superior over other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 42-year-old male enrollee has requested authorization and coverage for lumbar total disc arthroplasty (artificial disc). 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 the medical literature has not demonstrated the superior effectiveness of the requested services.  The use of total disc arthroplasty has not been shown to be more beneficial than other more accepted surgical treatments such as fusion in the lumbar region.  The long-term durability of these devices is unknown when subjected to the stresses of the lumbar spine.  Therefore, the requested lumbar total disc arthroplasty (artificial disc) is not likely to be of greater benefit than other treatment options.  For these reasons, 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: Upheld

Summary Reviewer 1

A 55-year-old female enrollee has requested authorization and coverage for arthrodesis of sacroiliac (SI) joint (27279). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees SI joint pain. The physician reviewer found that the International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive SI joint fusion provide specific indications for surgery. ISASS criteria includes: significant SI joint pain or significant limitations in activities of daily living because of SI joint pain; SI joint pain confirmed by at least three positive SI joint provocative tests; confirmation of the SI joint as a pain generator with at least 75% decrease in pain following fluoroscopically guided diagnostic intra-articular SI joint block in the immediate post-injection period; failure to respond to at least six months of non-surgical treatment including medications, rest, physical therapy, and SI joint steroid injection or rhizotomy; and, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been clearly considered, investigated and ruled out. In this case, the patient presents with chronic left SI joint pain. Functional limitations are noted in activities of daily living and ambulatory ability. The records document up to three positive provocative SI joint tests on clinical examination. The provider reports a 75% reduction in pain with diagnostic injections, but the patient reports no benefit with any treatment attempted. Conservative treatment has included medications, activity modification, massage, acupuncture, and physical therapy. She has been diagnosed with a painful left SI joint condition but there is no imaging evidence consistent with SI joint spondyloarthropathy, degenerative sacroiliitis, or SI joint disruption. In addition, there is concern for lumbar spine and left hip pain generation. Therefore, the requested arthrodesis of SI joint (CPT code 27279) 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 2

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 Arthroscopic resection is a very good option for medial plicae that do not respond to conservative treatment, and it must be initiated as a first option when cartilage damage is suspected. Prejbeanu and colleagues performed a large study of 267 patients who underwent symptomatic medial plica resection and had good results with long-term follow-up documented. There is sufficient support for the services at issue in this clinical setting. In sum, knee arthroscopy synovectomy performed on 12/20/17 was likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 44-year-old female who presented to the emergency department on 10/13/19 with complaints of abdominal pain status post dirt bike accident. At the time of presentation, her vital signs were stable, with a heart rate of 112 and normal oxygen saturations on room air. The physician reviewer found that in this case, the patient was admitted in stable condition. Her pain was controlled with oral pain medications. She did not require any urgent surgery or procedures. Her vital signs were stable, and there was no evidence of hemodynamic instability or active bleeding. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting,
when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, inpatient admission provided from 10/13/19 through 10/14/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found there is support in the medical literature for the services at issue in this clinical setting. Gabriel has demonstrated in a small but hypothesis-driven randomized clinical trial that botulinum effectively addresses the sources of severe pain associated with postmastectomy reconstruction. Although there were not any notable differences in the use of narcotic, muscle relaxants, or anti-inflammatory drugs observed for the two groups in the first three days after surgery, the botulinum group used significantly fewer doses of narcotics and muscle relaxants from days seven to 45 of recovery (Gabriel).  Additionally, Gabriel found a statistically significant increase in the volume of expansion per office visit, leading to full expansion more quickly in the botulinum group than in the placebo group. Gabriels study is similar to the study by Layeeque and colleagues. In that trial, women injected with botulinum in the pectoral muscles in the time between mastectomy and tissue expander placement reported less postoperative pain and used fewer narcotics in the first 24 hours after surgery and in the final expansion period than patients who did not receive the agent. In sum, the use of Botox is an appropriate treatment for post-mastectomy breast reconstruction. For the reasons provided above, the Botox injections received on 10/9/14 and 10/29/15 were 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.