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

Summary Reviewer  
The patient is a 23-year-old female who presented to her provider on 4/27/22. The patient has 
requested reimbursement for air ambulance transport on 5/6/22. The physician reviewer found 
that at issue is whether air ambulance transport on 5/6/22 was medically necessary for the 
treatment of this patient. The submitted documentation supports the medical necessity of the 
service  at  issue.  In  this  case,  the  patient  had  an  extremely  low  body  mass  index  with 
hyponatremia, hypotension, and renal dysfunction due to severe anorexia nervosa. In the course 
of air ambulance transfer, the patient required numerous intravenous medications including 
Ativan, Zofran, and Fentanyl due to anxiety, nausea, and abdominal pain. The patient had non-
epileptiform seizure activity just prior to the flight and enroute to the receiving hospital. She 
continued to be hypotensive throughout the flight and required continuous cardiac monitoring. 
Given the significant morbidity and mortality associated with medical ramifications of severe 
malnutrition and anorexia nervosa, and this patients clearly compromised medical state leading 
up to the transfer to specialized care and enroute, the service at issue was medically indicated to 
safely  transfer  the  patient.  Therefore,  air  ambulance  transport  on  5/6/22  was  medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 59-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier assay performed on 10/12/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found the medical evidence supports the services at issue in this clinical setting.  Genetic testing is generally considered standard protocol on all fine needle aspirations performed on thyroid nodules.  There is sufficient literature demonstrating that this testing can be performed to avoid needless surgeries.  In this case, the results helped guide future management.  In sum, Afirma Gene Expression Classifier assay performed on 10/12/15 was likely to have been more efficacious than other modalities for evaluating this patient.  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 

A 20-year-old male enrollee has requested reimbursement for wilderness program services provided from 7/12/18 through 10/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that with regard to acute intoxication or withdrawal potential, there were no known signs of symptoms of withdrawal upon admission. However, the risk of protracted withdrawal symptoms, such as heightened anxiety, depression, leading to suicidal ideation warranted close monitoring and structure. In terms of biomedical conditions, the records noted a history of traumatic brain injury. As noted above, there are concerns regarding co-occurring traumatic brain injury and substance use disorder and the increased morbidity and mortality of continued substance use in patients with a known traumatic brain injury. With regard to emotional, behavioral, cognitive conditions, his mental status was sufficient to permit participation. Despite limitations placed on the patient by his parents, his behavior continued to escalate to the point that he was at high risk of harm to self or others if his substance use and related behaviors were not curtailed. He had failed lower levels of treatment to include psychiatric outpatient treatment (medication management and therapy) following his inpatient admission in June 2018. In terms of readiness to change, the patient initially had limited insight for need for treatment but relented due to his parents continued requests and his deteriorating condition prior to admission. He had demonstrated a known resistance to being controlled. His perspectives impaired his ability to make care decisions, as evidenced by his impulsive behaviors. With regard to relapse, continued use, or continued problem potential, the patient had risk-taking behavior that was escalating to the point of aggression and not responding to parental limits, leading to a prior inpatient psychiatric admission. However, after discharge from the hospital, little change occurred. His maladaptive behaviors, such as need for immediate gratification, poor judgment, limited coping skills and low frustration tolerance, placed him at imminent danger of relapse if not in a structured setting that provided tools for improved coping and living a sober lifestyle. In terms of recovery environment, the home setting (with his parents) was not conducive to continued recovery. Therefore, wilderness program services provided from 7/12/18 through 10/08/18 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that the limitations of mammography in the detection of breast cancer in patients with dense tissue have been well-documented. In patients with BRCA1 mutation, there is a markedly elevated lifetime risk of breast cancer exceeding 75%. MRI has been shown to be far superior to mammography in the detection of breast cancer. The medical evidence supports the services at issue in this clinical setting. Therefore, bilateral breast MRI performed on 1/28/18 was likely to have been of greater benefit than other methods of evaluating this patient. 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 32-year-old male enrollee has requested reimbursement for gene testing performed on 3/12/19. 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 melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx-Melanoma assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, gene testing performed on 3/12/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 64-year-old female with a longstanding history of eczema. The patient has 
requested authorization and coverage for Dupixent. The physician reviewer found that the 
submitted documentation supports the medical necessity of the requested medication. This 
patient has chronic recalcitrant eczema which has failed topical treatment. Dupilumab has been 
approved by the U.S. Food and Drug Administration (FDA) for patients with atopic eczema that 
warrants systemic treatment. This medication has been demonstrated to be safe and effective in 
this clinical setting. Therefore, Dupixent is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 12/18/15.  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 the current medical evidence supports the services at issue in this patients case.  The addition of digital breast tomosynthesis to screening mammography reduces false positives and increases cancer detection when compared to two-dimensional mammography alone.  Breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries).  The medical literature supports the use of breast tomosynthesis in the routine screening population.  Therefore, digital breast tomosynthesis performed on 12/18/15 was likely to have been of greater benefit than other methods of evaluating this patient.  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 2

A 33-year-old female enrollee has requested reimbursement for fecal lactoferrin testing performed on 12/06/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the patient had gastrointestinal symptoms, such as mucus in her stool, which could be consistent with irritable bowel syndrome, or with inflammatory bowel disease (CrohnAaas disease or ulcerative colitis). The American College of Gastroenterology guidelines for the management of CrohnAaas disease support the use of fecal calprotectin testing, stating that when there are symptoms concerning for active CrohnAaas disease, AaAFecal calprotectin and fecal lactoferrin measurements may have an adjunctive role in monitoring disease activityAaA and AaAstudies have shown that both fecal lactoferrin and fecal calprotectin are sensitive markers of disease activity and correlate with a number of the endoscopic activity indicesAaA Lactoferrin testing is a highly sensitive, low-risk test to assess for inflammatory bowel disease. Therefore, fecal lactoferrin testing performed on 12/06/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 33-year-old female enrollee has requested reimbursement for homocysteine testing, Factor V Leiden genetic testing and methylenetetrahydrofolate reductase (MTHFR) performed on 8/7/15. The Health Insurer has denied this request indicating that the services at were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that according to the medical records the patient has undergone one pregnancy loss. The American Society for Reproductive Medicine, in its Practice Committee Opinion, defines recurrent pregnancy loss as the occurrence of two or more miscarriages. Therefore the patient does not meet the standard of care definition of recurrent pregnancy loss. The American Society for Reproductive Medicine, in its practice committee opinion states Screening for inherited thrombophilias (specifically, Factor V Leiden and the prothrombin gene mutations, protein C, protein S, and antithrombin deficiencies) may be clinically justified when a patient has a personal history of venous thromboembolism in the setting of a non-recurrent risk factor (such as surgery) or a first-degree relative with a known or suspected high-risk thrombophilia. Although an association between hereditary thrombophilias and fetal loss has been suggested, prospective cohort studies have failed to confirm this. Routine testing of women with recurrent pregnancy loss for inherited thrombophilias is not currently recommended. There is no evidence that the patient has a personal or family history of a thrombophilia. Therefore there is a lack of support for the Factor V Leiden testing or any other tests for inherited thrombophilias. In addition, there is a lack of support in the peer-reviewed literature that a significant association of MTHFR and recurrent miscarriage exists. Therefore, MTHFR testing is not within the standard of care and was not likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for 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

The patient is a 41-year-old male who was involved in a motor vehicle accident in 2002, which resulted in a left brachial plexus injury. There has been residual severe left arm weakness distal to the shoulder despite extensive treatment including nerve transfers in 2003 and 2005, static orthoses and physical therapy.  He has been effectively one handed functionally. A myoelectric elbow-wrist-hand orthosis has been recommended for promotion of bimanual activities and protection of the sound contralateral upper limb from overuse syndrome. The patient has requested authorization and coverage for MyoPro device. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patients medical condition. The medical literature regarding the potential benefit from this type of device is limited to preclinical work, developmental work and small anecdotal reports. The requested device is not yet proven to provide functional improvements that could not be achieved through standard occupational therapy interventions with static orthoses and durable medical device used for assisting with self care and other activities.  It is not well known whether users will adopt the device for regular functional use in the long term or if the device itself causes injuries with long term use (e.g., at the shoulder due to the equipments weight). Current commercially available iterations of this type of device remain heavy, bulky, difficult to wear, and difficult to use on a practical basis.  Further study is required to determine its efficacy and safety when compared to standard means of treatment.  As such, the requested device is not reasonably expected to favorably affect this patients clinical or functional outcomes. Therefore, the MyoPro device is not likely to be more effective than the standard therapies available for the treatment of this patients medical condition.  Based upon the information set forth above, the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. 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 as noted 
by  Marion  and  colleagues,  chromoendoscopy  is  supported  as  superior  to  alternatives  for 
localization  of  dysplasia  in  randomized  trials.  Per  American  Society  for  Gastrointestinal 
Endoscopy (ASGE) guidelines for inflammatory bowel disease, chromoendoscopy allows better 
characterization  of  visible  lesions  as  endoscopically  resectable  or  unresectable,  and 
chromoendoscopy with targeted biopsies is the preferred surveillance technique to maximize 
dysplasia  detection.  Per  American  Gastroenterological  Association  guidelines,  Dye  spray 
chromoendoscopy...should be considered in all persons with colonic inflammatory bowel disease 
undergoing surveillance colonoscopy, particularly if a standard definition endoscope is used or if 
there is a history of dysplasia. The patient has had a colon polyp (of the serrated type) in the 
past, and aside from that, warrants surveillance biopsies for dysplasia given the diagnosis of 
ulcerative colitis. Per the guidelines cited above, surveillance colonoscopies should be performed 
using  chromoendoscopy  when  possible.  Therefore,  colorectal  cancer  screening  using 
chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22 was likely 
to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
The parent of a 16-year-old male insured has requested reimbursement for a laboratory test 
performed on 2/10/23. The Health Insurer has denied this request indicating that the services at 
issue were considered investigational for the evaluation of the insureds Chrons disease. 
The physician reviewer found that the use of infliximab trough levels and antibodies have become 
standard in clinical practice to determine if infliximab dosing is appropriate and whether a patient 
has lost, or is likely to lose, responsiveness to treatment due to the formation of antibodies to 
infliximab. These lab tests lead to adjustments in treatment, as low serum drug troughs and 
elevated antibody levels are predictive and explanatory of disease flare. Routine monitoring of 
asymptomatic patients is now being done to prevent flares by ensuring appropriate drug levels. 
According to Hyams and colleagues, It is clear that whether monotherapy or combination biologic 
therapy is used, we are now in the age where monitoring drug and antibody levels should be 
considered standard of care. Although the use of proactive versus reactive monitoring remains in 
question, measurement of infliximab levels and antibodies is considered the standard of care. In 
this case, the lab testing was performed in response to a dosage change and was thus appropriate. 
All told, the laboratory test performed on 2/10/23 was likely to have been more beneficial for the 
evaluation of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 49-year-old transgender female who is seeking facial feminization surgery. Her primary care provider, surgeon, and psychologist all assert that facial feminization surgery is a medically necessary treatment for her gender dysphoria. The physician reviewer found that facial feminization surgery is medically necessary for some patients as a treatment for gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health (WPATH) position statement notes, aNon-genital surgical proceduresa notably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a In this case, the patient has been diagnosed with gender dysphoria. The medical evidence supports the requested services in this clinical setting. Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 58-year-old female who has been diagnosed with multiple sclerosis and type 1 diabetes.  The patient has requested authorization and coverage for Acthar (corticotropin injectable gel 80 U/ml). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that standard therapy for acute exacerbations of multiple sclerosis has been high-dose corticosteroid therapy. Adrenocorticotropic hormone (ACTH, Acthar Gel) is also approved by the U.S. Food and Drug Administration (FDA) for the treatment of exacerbations of multiple sclerosis in adults.  Other therapies include plasmapharesis and intravenous immunoglobulin (IVIG). Plasmapharesis is generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids or ACTH. IVIG is sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but there is a lack of consistent evidence for its use in relapse management. Ross and colleagues noted, aAdrenocorticotropic hormone gel, as previously noted, may be considered as an alternative treatment of multiple sclerosis relapses. In our experience, reasons for using adrenocorticotropic hormone include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids.a In a randomized, open-label, crossover study, Bell and colleagues evaluated 18 patients with multiple sclerosis treated with subcutaneous Acthar Gel and intravenous methylprednisolone. Preliminary results suggest that fewer drug-related adverse effects occurred with Acthar Gel than intravenous methylprednisolone for treatment of multiple sclerosis exacerbations. In this case, the patient has multiple sclerosis and is seeking approval for Acthar Gel for treatment of acute exacerbations. Acthar Gel is currently an FDA approved therapy for multiple sclerosis exacerbations, and the studies noted above report less adverse effects with Acthar Gel and comparable efficacy and treatment outcomes compared with intravenous corticosteroid therapy.  Clinically, Acthar Gel has been effective for the patient and she has not experienced any significant side effects with Acthar Gel. Therefore, Acthar (corticotropin injectable gel 80 U/ml) is medically necessary for the treatment of this patient.