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

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this patients case. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. In sum, breast tomosynthesis (three-dimensional mammogram) performed on 10/31/16 was likely to have been more efficacious than other methods of evaluating this patient.  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 56-year-old male enrollee has requested reimbursement for DecisionDX-Melanoma test performed on 8/4/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma] The physician reviewer found the current standard of care, based on National Comprehensive Cancer Network Guidelines (NCCN) guidelines, uses the tumor node metastasis (TNM) cancer staging system to determine a recommendation for additional imaging tests or for additional treatment. The NCCN guidelines state that there is an interest in newer prognostic molecular techniques such as gene expression profiling to determine low versus high risk for metastases. However, routine baseline genetic testing of primary cutaneous melanoma is not recommended outside of a clinical trial. As such, in this patients case, the use of DecisionDX-Melanoma assay was not likely to be more effective than available standard staging systems for the evaluation of this patient. Therefore, for the reasons stated 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 36-year-old female enrollee has requested authorization and coverage for Flex Walk System and multiaxial rotation unit for right leg. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees bilateral transtibial amputation. The physician reviewer found that in this case, the patients functional condition is expected to increase by two categories with the addition of the new components. As noted by Armannsdottir and colleagues, following transfemoral amputation numerous changes in movement patterns during gait can occur. The authors reported that six weeks of individualized training with a microprocessor controlled prosthetic foot with active/inactive ankle dorsiflexion resulted in improved gait quality. The requested equipment is expected to allow complete independent function in all ambulatory environments. Given this support, the requested Flex Walk System and multiaxial rotation unit for right leg is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested equipment is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for adolescent mental health residential treatment services with New Vision Wilderness, an out-of-state wilderness program, provided from 11/01/19 through 2/10/20. 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 the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 4. The patient had serious risk of harm, due to significant impulsivity, with poor judgment and insight, and this was significantly endangering to himself or others. He had been punching walls, hitting mother and transport team member. In terms of functional status, the records support a score of 4. The patient had serious functional impairment, due to serious deterioration of interpersonal interactions, with consistent conflict as well as sporadic school attendance. With regard to comorbidity, the records support a score of 4. The patient had uncontrolled substance use that posed a serious threat to health. In terms of level of environmental stress, the records support a score of 3. The patient had a moderately stressful environment, due to estrangement from his father, conflict with his mother, and school difficulties. With regard to level of support of the recovery environment, the records support a score of 2. The patients mother was involved in treatment and treatment planning. In terms of resiliency and treatment history, the records support a score of 3. The patient had a lack of improvement at lower levels of care, and refused to attend intensive outpatient program treatment. With regard to treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to minimization of the problems caused by his substance abuse, refusal to participate in intensive outpatient program, and initial resistance to being transported to the wilderness program. Therefore, the patient has a total score of 23. Due to serious risk of harm, the recommended level of care is medically monitored residence-based services. In this case, the therapeutic services offered at the wilderness program (individual and group therapy) are not different from those offered at other residential treatment programs. The fact that they took place in a wilderness milieu does not mean that they are not evidence-based. Therefore, adolescent mental health residential treatment services with New Vision Wilderness, an out-of-state wilderness program, provided from 11/01/19 through 2/10/20 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 44-year-old female who has a personal history of several malignancies including bilateral invasive lobular breast cancer at age 42, non-Hodgkins lymphoma in 1997, thyroid cancer in 1998, and a mucoepidermoid carcinoma of the trachea in 2009. Her family history is significant for a sister with thyroid cancer at age 34.  The records noted a sister was diagnosed with non-Hodgkins lymphoma at 42. Her paternal grandmother was diagnosed with uterine cancer in her 60s, her mother was diagnosed with thyroid cancer at 66, two maternal cousins were diagnosed with thyroid cancer, and a maternal uncle was diagnosed with leukemia at age 18. The patient has requested reimbursement for gene testing performed on 11/28/16.  The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. This patient has an extensive personal history of cancer, including breast cancer before the age of 50 that was bilateral. Her family history is also suggestive of a familial genetic predisposition to thyroid cancer on the maternal side. More than one gene could explain the patients genetic risk of cancer. If a gene is identified, this could help guide prevention and treatment strategies.  This patient meets criteria for BRCA1 and BRCA2 testing. The largest studies reporting on the outcomes of multigene testing indicate that among women tested in clinical settings, about 5 to 10 percent have a BRCA1 or BRCA2 mutation, and about 4 to 7 percent have a harmful mutation in another gene associated with high to moderate risks of breast and/or ovarian cancer, or a mutation in a newer gene that may also be associated with increased risks for these cancers. She also has a significant family history, and testing positive for a mutation would guide additional therapy, such as mastectomy or oophorectomy as well as how to manage her screening for another breast cancer or other cancer. The medical evidence supports the services at issue in this clinical setting.  All told, gene testing performed on 11/28/16 was likely to have been more effective 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential mental health treatment provided from 4/01/14 through 5/20/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found there is a lack of support for the services at issue in this patients case.  She had no substance abuse problems.  She was engaged and an active participant in the treatment process.  She was independent in her activities of daily living, and there were no cognitive difficulties.  Her parents were active participants in the family process.  The patient did not require 24-hour supervision in the restricted setting of residential.  Although she required treatment, her medication management and other treatment could have been conducted at a lower level of care.  There was no documentation as to the patients response to medications or assessment for side effects.  There was no comprehensive intake, history and physical, or initial psychiatric evaluation.  Overall, the documentation was inadequate to support the medical necessity for 24-hour supervised care in a residential setting.  In sum, residential mental health treatment provided from 4/01/14 through 5/20/15 were 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: Overturned

Summary Reviewer 2
The parent of a four-year-old male enrollee has requested authorization and coverage for Botox 100 units. 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 there is sufficient support for the requested services in this clinical setting. The records document cerebral palsy and constipation refractory to medical management. The patient has tried several medications and cleanouts, without success. This treatment is commonly used in motility centers for children with difficulty stooling due to problems relaxing the muscles. Studies have shown that it can be safe and effective for constipation that is difficult to treat. Therefore, J0585 - Botox 100 units are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 59-year-old male has requested authorization and coverage for CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees gastroesophageal reflux disease. The physician reviewer found that appropriate patient selection is crucial before anti-reflux procedures. Transoral incisionless fundoplication has shown durable response for a select population of gastroesophageal reflux disease patients. However, the severity of this patients esophageal dysmotility disqualifies him as an ideal candidate for the proposed transoral incisionless fundoplication procedure. As such, CPT 43210 (transoral incisionless fundoplication procedure utilizing the EsoPhyx device) is not likely to be more efficacious than other treatment options. 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: Upheld

Summary Reviewer 2

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 there is a lack of support for the requested medication in this clinical setting. This patient has been diagnosed with gastroesophageal reflux disease. On 1/07/19, while the patient was on lansoprazole, the provider suggested a trial of hypoallergenic formula. The provider also recommended gastroenterology evaluation. On 2/15/19, the records noted that that the patient was intolerant of the hypoallergenic formula. However, the records do not provide additional details regarding the symptoms of intolerance. Proton pump inhibitor therapy is recommended in infants only when there are findings of erosive esophagitis or in the presence of certain anatomic abnormalities (such as repaired tracheoesophageal fistula/esophageal atresia). Given that esophagitis was not documented in this case, lansoprazole is not likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 61-year-old female enrollee has requested authorization and coverage for a series of left knee Synvisc One injections. The Health Plan has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees osteoarthritis.  The physician reviewer found that current evidence-based guidelines recommend hyaluronic acid injections in the knee as a possible option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Guidelines state that there is no maximum amount of injections established by high quality scientific evidence, nor is one type of viscosupplementation supported over another. This patient presents with chronic left knee pain with intermittent swelling, grinding, and instability. She is status post ACL reconstruction. She reports functional difficulty interfering with her work ability. She had failed reasonable conservative treatment, including medications, corticosteroid injections and physical therapy. Criteria have been met for the use of viscosupplementation for this patients medical condition. However, current evidence-based guidelines and peer-reviewed literature indicate that there is a general lack of reliable evidence that any specific brand is superior to others. There is no compelling rationale presented to support the medical necessity of Synvisc One as the initial viscosupplementation agent. Therefore, the requested series of left knee Synvisc One injections is not medically necessary for the treatment of this patient. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 54-year-old female who presented to her provider on 10/12/21 for evaluation 
of chronic neck pain. The patient has requested reimbursement for code 01936-QZ 20 units 
anesthesia for percutaneous image guided procedures on the spine and spinal cord performed 
on 11/04/21. The physician reviewer found that the 2019 American Society of Interventional 
Pain Physicians (ASIPP) guidelines on procedural sedation state, Given that patients 
undergoing pain procedures typically are anxious and in pain, mild to moderate sedation is 
acceptable for many patients. The authors went on to further state, "Deeper sedation should 
only be undertaken in the presence of anesthesia providers and for patients who have high 
anxiety, complex pharmacotherapy, or a low pain threshold when undergoing more painful 
interventional pain procedures. In special cases, the risk of patient movement during a 
procedure resulting in potential inadvertent injury may justify a deeper anesthetic state. The 
2016 American Society of Anesthesiologists (ASA) Statement on Anesthetic Care During 
Interventional Pain Procedures for Adults states, Patient anxiety and/or medical comorbidities 
may be an indication for moderate (conscious) sedation or anesthesia care team services. In 
addition, procedures that require the patient to remain motionless for a prolonged period of 
time and/or remain in a painful position may require moderate sedation or anesthesia care 
team services. In this case, the patient was required to undergo a cervical transforaminal 
epidural steroid injection as per recommendations of her neurosurgeon. She has confirmed 
needle phobia and anxiety that required previous anesthetic care during those procedures. 
Furthermore, the cervical transforaminal injection inherently carries a great deal of risk of 
intravascular injection, nerve root injury, seizure, stroke and paralysis. Based on the presence of 
pre-existing anxiety, needle phobia, and danger associated with movement in this procedure, 
the anesthesia used for the procedure was medically necessary. Therefore, code 01936-QZ 20 
units anesthesia for percutaneous image guided procedures on the spine and spinal cord 
performed on 11/04/21 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 20-year-old male enrollee has requested authorization and coverage for chondrocyte implantation with Denovo. 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 submitted documentation supports the superior efficacy of the requested services.  The patient is skeletally mature and he has had localized knee pain for greater than six months.  The lesion present appears to be discreet and single and does not include evidence for a kissing lesion.  No systemic arthritic conditions have been diagnosed.  When nonsurgical treatment has become ineffective for patellofemoral osteoarthritis, other procedures are appropriate.  Depending upon the specific findings for a given patient, these procedures may include soft tissue realignment either through lateral release or tubercle transfer and/or autologous chondrocyte implantation for focal cartilage defects.  The specific combination of realignment procedures and cartilage resurfacing procedures depend upon the clinical problems presented to the surgeon.  While additional lesions including trochlear lesions may not necessarily rule out cartilage transplantation, this patient does not have a trochlear lesion by either direct inspection on arthroscopy or indirect visualization through MRI.  This increases the likelihood that a satisfactory clinical result will be obtained.  Given this patients young age, if the lesion is not addressed then there will be progressive deterioration of the patellofemoral joint.  All told, the requested chondrocyte implantation with Denovo is likely to be more efficacious than other treatment alternatives.  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: Overturned

Summary Reviewer 

A 49-year-old female enrollee has requested authorization and coverage for Ubrelvy. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a history of chronic migraine, and she has failed traditional migraine treatments. The provider notes that the patient had modest benefit with the use of triptan medications. The current method of treating intractable migraine headaches, especially during acute attacks, is the use of medications with various mechanisms of action. Since triptans are somewhat effective for this patient, the use of a calcitonin gene-related peptide (CGRP) antagonist such as Ubrelvy is likely to provide added benefit, since there is a different mechanism of action. There is sufficient support for the requested medication in this clinical setting. Therefore, Ubrelvy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for mental health inpatient treatment provided from 11/24/15 through 11/30/15. 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 the submitted documentation demonstrates the medical necessity of the services at issue. 
On 11/24/15, the patients Zoloft and Abilify dosages were increased, as she was still depressed. Furthermore, she had been placed on one to one staffing because of self-abusing. The records reflect that the patient was still unstable. The submitted documentation supports the continuation of this patients inpatient treatment in order to stabilize her prior to discharge. In addition, the patients recent history of decompensation after stepping down for only a few days to PHP further increased the likelihood of a relapse if she were discharged from acute care prematurely.  All told, the services at issue were medically prudent and necessary in the treatment of the patients behavioral health condition. The Health Insurers denial should be overturned.