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

Summary Reviewer 

The parent of a 16-year-old male has requested authorization and coverage for Norditropin injections 30/3 ml. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrolleei12s medical condition. The physician reviewer found that guidelines recommend the use of growth hormone therapy for idiopathic short stature when height is 2.2 standard deviation below the mean for age and sex. This patienti12s height was 1.88 standard deviations below the mean and did not meet the definition of idiopathic short stature. He had a bone age that was delayed approximately two years. The exact height of the patient and the estimated predicted height based on this bone age prior to initiation of therapy was not provided. The patient has a history of delayed puberty, which is a cause of short stature. Short stature secondary to delayed puberty can cause temporarily low growth velocity, but the final height is normal, without therapy. Growth hormone therapy is not indicated for the diagnosis of short stature due to delayed puberty. The delayed bone age supports the diagnosis of constitutional delay of growth. The Tanner stage (puberty assessment) of the patient before the initiation of growth hormone therapy is not provided. The growth velocity without information regarding the puberty stage can be misleading. The growth velocity is noted as 2 cm per year, although the growth chart does not support this. Growth velocities that are not extrapolated from the last 12 months might be inaccurate due to short intervals of measurements. The patient had a good response to growth hormone therapy. However, a child with constitutional delay of puberty would catch up anyway, as puberty would advance the growth velocity. The medical evidence does not support the requested medication in this clinical setting. Therefore, Norditropin is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 41-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 1/17/20. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index is thought to add a bit to these statistics. DecisionDx-Melanoma assay is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who underwent a sentinel node biopsy, which this patient has not had. It is not at all clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 1/17/20 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 44-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/28/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees melanoma. The physician 
reviewer found that the use of gene expression profiling (GEP) testing according to specific 
American Joint Committee on Cancer (AJCC) melanoma stage (before or after sentinel lymph 
node biopsy) requires further prospective investigation in large, contemporary datasets of 
unselected patients. Prognostic GEP testing to differentiate melanomas at low versus high risk 
for metastasis should not replace pathologic staging procedures. Moreover, since there is a low 
probability of metastasis in stage I (T1) melanoma and a higher proportion of false-positive 
results,  GEP  testing  should  not  guide  clinical  decision-making  in  this  subgroup.  National 
Comprehensive Cancer Network guidelines do not support the use of GEP tests in this clinical 
setting. Therefore, DecisionDx-Melanoma testing performed on 7/28/21 was not likely to have 
been more beneficial for evaluation of the patients condition than any available standard 
therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 57-year-old male enrollee has requested authorization and coverage for the Inspire hypoglossal nerve stimulation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea.  The physician reviewer found that the medical data submitted for this case has been critically reviewed and documents a history of longstanding obstructive sleep apnea syndrome. The patient has failed to improve despite surgical interventions including standard therapy such as UPPP, hyoid suspension, genioglossus advancement and oral mandibular advancement prostheses. The patients symptomatology and polysomnogram results continue to show that the patient has fairly severe obstructive sleep apnea with apnea/hypopnea index greater than 42 episodes per hour sleep. In addition, the patient has become totally intolerant of the use of CPAP with full face mask and other masks because of the high pressures involved. Thus, the records indicate that this patient meets the clinical criteria of alternative therapy of implantation of a hypoglossal nerve stimulator (Certal, et al). Soose and colleagues reported that in patients with moderate to severe obstructive sleep apnea and a body mass index of 32 or less, hypoglossal cranial nerve stimulation therapy can provide significant improvement in important sleep related quality-of-life outcome measures and the effect is maintained across a two-year follow-up period. Given these findings, the requested Inspire hypoglossal nerve stimulation therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 42-year-old male enrollee has requested authorization and coverage for an implanted neurostimulator pulse generator system. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that Hypoglossal nerve stimulation is an emerging technology for the treatment of OSA. While initial studies have shown promise, conclusions cannot be drawn from the available evidence. The optimal patient selection criteria for the use of hypoglossal nerve stimulation has not been defined nor have the findings of the original studies been replicated. At this time, the practice guidelines on the management of OSA do not recommend the use of hypoglossal nerve simulator. All told, the requested implantation of a hypoglossal nerve simulator for treatment of this patients OSA 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 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: Upheld

Summary Reviewer 

The parent of a 16-year-old female enrollee has requested reimbursement for mental health residential treatment provided from 2/21/19 forward. 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 in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. During the dates of services at issue, in terms of risk of harm, the records support a score of 1. The patient has not had self-harm behaviors since 1/03/19. With regards to functional status, the records support a score of 2. The patient reported urges to engage in eating disorder behavior without participating in eating disorder behaviors. In terms of comorbidity, the records support a score of 3. The patients diagnoses included anorexia nervosa, major depressive disorder and generalized anxiety disorder with a history of suicide attempts in the past and self-injurious behavior. With regards to level of stress of the recovery environment, the records supported a score of 2. The patients family was engaged in treatment and recovery. In terms of level of support of the recovery environment, the records support a score of 2. The parents were engaged in treatment. In terms of resiliency and treatment history, the records support a score of 2. On 2/25/19, the patient noted decreased depression. No self-harm behavior or urges were noted. In terms of acceptance and engagement of the child, the records supported a score of 2. On 2/25/19, the patient reported feeling more hopeful, and her behavior was described as more social. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents were actively involved in treatment. Thus, the patient has a composite score of 16. This score correlated with outpatient services. Therefore, mental health residential treatment provided from 2/21/19 forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 35-year-old female enrollee has requested reimbursement for NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees pregnancy. The physician reviewer found that the Harmony Prenatal test provided on 11/12/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient was estimated to be over 35 years of age at the time of delivery. Thus, Harmony Prenatal test screening was indicated for this patient based on the support in the peer-reviewed the literature and national guidelines. However, the NxGen MDx Universal panel was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Testing utilizing the NxGen MDx Universal panel is indicated for patients with a specific family history. A review of this patients chart does not document any specific risk factors as her history of a previous pregnancy loss secondary to an incompetent cervix is not a factor indicating a specific risk of a genetic disorder. Based upon the information set forth above, a portion of 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 partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 62-year-old male enrollee has requested reimbursement for long term acute care provided from 10/30/18 through 1/11/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that rehabilitation therapy services can be delivered in a wide variety of settings across the care continuum. Post-acute settings differ in the types of available rehabilitation therapies, intensity of therapy, and the level of medical and nursing support. Long-term acute care hospitals offer physical and occupational therapy, 24-hour skilled nursing care and a clinician available 24 hours per day. The medical providers are able to care for active/ongoing medical conditions requiring a clinician-level care (e.g., ventilator-dependent). The long-term acute care hospital setting is considered when the patients need for nursing and rehabilitative services are such that only an inpatient long-term acute care hospital setting can meet the requirements, and the expected length of stay is greater than 25 days. In this case, the documentation does not support that the patient required complex medical treatment (e.g., multiple and prolonged intravenous therapies; monitoring of significantly medically active conditions requiring clinical assessment six or more times a day; multiple and frequent intervention of at least six or more times a day, like ventilator management, cardiac monitoring, complex wound care for multiple wounds stages 3 and above; and the need for specialized high-tech equipment like cardiac monitors, on-site dialysis, or surgical suites) as of 10/30/18. The patient did not require services at the long-term acute care hospital setting that were not available at the acute care hospital or the skilled nursing facility. The requested treatments were not medically necessary at the long-term acute care hospital level of care from 10/30/18 through 1/10/19. Although the patient required hemodialysis, nutrition via a feeding tube and continued wound care, he was medically stable as of 10/30/18 and could have received services at a lower level of care. Therefore, long-term acute care provided from 10/30/18 through 1/11/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for a hysterectomy and hospital stay from 12/28/15 through 12/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who has had a history of chronic pelvic and abdominal pain.  The physician reviewer found that there is sufficient support for the medical necessity for the services at issue in this clinical setting. Chronic pelvic pain is a complex problem and it is poorly understood. It is typically very difficult to treat, as the disease process is multifactorial without one specific etiology, and clinically can present in different ways. Some common diagnoses include endometriosis, adhesions, irritable bowel syndrome, and interstitial cystitis. In this patients case, she had the appropriate workup to evaluate her chronic pelvic/abdominal pain to suggest that surgical management would be appropriate. An evaluation was performed between her primary care provider, gastroenterologist, general surgeon, urologist and gynecologist to determine the etiology of her symptoms. Moreover, the gynecologist indicated no signs and symptoms of depression as a contributing factor to her chronic pelvic pain that she would have required a psychologic evaluation. Given the multifactorial nature of the patients chronic pelvic pain, it was appropriate to have many specialties involved in the workup. She had a slightly enlarged retroverted and extremely tender uterus that was determined to be the cause of her pain. The decision at the time of laparoscopic evaluation was that the patient needed surgical management of her chronic pelvic pain. As such, medical management in this setting is  not likely to be successful. All told, the hysterectomy and hospital stay from 12/28/15 through 12/31/15 were medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for the bilateral three dimensional digital breast tomosynthesis provided on 10/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. Overall, three dimensional digital breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, the addition of breast tomosynthesis has been found to increase cancer detection. Thus, the digital breast tomosynthesis on 10/16/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is an 18-year-old female who presented to her provider on 11/06/20. Per the records, she had fallen from a horse in November 2020 with resultant left shoulder pain. The patient has requested reimbursement for MRI performed on 11/12/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the American College of Radiology (ACR) has established appropriateness criteria for various clinical presentations and disorders, in order to better guide clinicians on the most efficacious and efficient use of imaging. As a first imaging modality, plain films are recommended. However, when plain films are negative, the next imaging test recommended is an unenhanced MRI of the shoulder. As noted by the ACR, MRI Shoulder Non-contrast MRI is a reasonable imaging study in the setting of acute nonlocalized traumatic shoulder pain and noncontributory radiographs. In the acute trauma setting, noncontrast MRI may be preferred to magnetic resonance (MR) arthrography, as acute intra-articular pathology will typically produce significant joint effusion for assessment of intra-articular soft-tissue structures. MRI is the preferred imaging modality in assessing extra-articular soft-tissue traumatic pathology such as capsular and ligament tears. MRI is also sensitive for diagnosing bone marrow contusion and has been shown to be beneficial in assessing shoulder physeal injuries in pediatric patients. In general, it is a widespread clinical practice to follow plain x-rays with an MRI, especially in a young patient with an immediate traumatic event. Significant issues, such as a labral tear or rotator cuff tear, can be best imaged with MRI. Despite physical therapy, these types of lesions generally do not heal themselves. Therefore, MRI performed on 11/12/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 60-year-old male enrollee has requested authorization and coverage for 18F-NaF positron emission tomography/computed tomography (PET/CT) scan. The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that the patient does not meet the current guidelines for the requested 18F-NaF PET/CT scan at this time. The National Comprehensive Cancer Network (NCCN) guidelines indicate that although sodium fluoride PET/CT may indeed be a promising technique in the re-staging of prostate cancer, the peer-reviewed medical literature and standards of care do not support the routine use of this study in this clinical setting. All told, the requested 18F-NaF PET/CT scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested diagnostic procedure is 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 31-year-old female enrollee has requested reimbursement for osteochondral knee autograft CPT code 27416 performed on 3/7/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who had injured her left knee.The physician reviewer found there is sufficient support in the medical literature for the efficacy of the services at issue in this clinical setting. Current evidence based medical literature recommends osteochondral autograft transplant surgery (OATS) when specific criteria have been met. Indications for surgery include conservative treatment (medications or physical therapy) plus subjective clinical findings of joint pain and swelling. Objective clinical findings include failure of previous subchondral drilling or microfracture, larger full thickness chondral defects that measure less than 3 cm2 on the weight bearing portion of the medial or lateral femoral condyle, intact and fully functional menisci and ligaments, normal knee alignment, normal joint space, and body mass index (BMI) less than 35. Additionally, there must be imaging evidence of chondral defect on the weight bearing portion of the medial or lateral femoral condyle. Gudas and colleagues concluded that the OAT technique for articular cartilage defect or osteochondral defect repair in the athletic population allows for a higher rate of return to and maintenance of sports at the preinjury level compared with microfracture. This patient presented with left knee pain and swelling that was significantly limiting her normal daily activities. The record indicates that her BMI was less than 35. Clinical examination findings were consistent with imaging evidence of a full thickness chondral defect on the lateral femoral condyle measuring less than 1 cm2. There was also imaging evidence of a small posterior tibial plateau tibial defect and loose bodies. The orthopedic surgeon reported that there was no full thickness or kissing lesion present on the tibia corresponding to the femoral lesion. Reasonable conservative treatment, including ice, NSAIDs, and activity modification, and failure were documented. As such, current peer reviewed medical literature supports the use of OATS for this patient over other procedures for return to and maintenance of sports at a pre-injury level. Therefore, osteochondral knee autograft, CPT code 27416 performed on 3/7/17 was likely to have been more beneficial for treatment of this 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.