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

Summary Reviewer 2


A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 clinical setting.  Due to the tomographic nature of the technique, breast tomosynthesis allows radiologists to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers.  In this case, it was more advantageous for the patient to have her mammogram include breast tomosynthesis than having had it with two-dimensional imaging alone.  Therefore, breast tomosynthesis performed on 7/13/15 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 


A 48-year-old female enrollee has requested reimbursement for CPT codes 64483 and 64484 provided on 10/11/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollees lumbar radiculitis. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. There is no documentation of detailed neurologic physical examination, trials of physical therapy, home exercise program, chiropractic care, or other conservative therapies. Per the records, there is a lack of documentation of trial of conservative therapies. There is no documentation of the results of the first or second transforaminal epidural steroid injections, as is the standard of care.  There is a lack of support for the services at issue in this clinical setting.  All told, CPT codes 64483 and 64484 provided on 10/11/16 were not medically necessary 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 1



A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the infliximab antibody testing performed on 3/30/15 was not likely to be more effective for this patient than other available options. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. There are few well controlled clinical trials to confirm that use of the infliximab antibody testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al). At this time it has not been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Given the above, the testing at issue was 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, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 49-year-old female enrollee has requested reimbursement for polymerase 
chain reaction (PCR) testing performed on 4/29/19. 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 PCR testing has been compared to 
traditional testing for vaginitis. The literature supports the use of PCR 
testing because it results in significantly higher sensitivity and 
negative predictive value than clinical diagnosis or clinical testing. 
The test may be used to detect more than one cause for vaginitis. PCR 
testing is a means of accurate detection that allows for appropriate 
treatment. The medical evidence supports the services at issue this 
 in 
patients case. Therefore, PCR testing performed on 4/29/19 was likely to 
have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 37-year-old male enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that this patients records support a diagnosis of GERD based on pH recording. However, the documentation states that the patient benefited to a significant degree from acid suppression treatment in the past and the failure he reportedly experienced with proton pump inhibitor (PPI) agents did not specify dosage of acid suppressants currently employed. Also, implantation of LINX in this patients setting must be approached with caution given his manometrically documented dysmotility, which is considered a contraindication (Lipham, et al). As such, the requested LINX procedure 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that the ExoSym kinetic orthosis is a customizable energy-storing device that is designed to support and protect an array of lower extremity limb injuries. However, at this time, there is a lack of evidence to support that the published results can be duplicated on a reliable basis. Until quality data becomes available, this orthosis does not have adequate support for use outside of a clinical trial. Accordingly, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was 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 device at issue was 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 the outpatient papanicolaou smear testing performed on 7/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees abnormal and showed atypical squamous cell of undetermined significance (ASC-US) and high risk human papilloma virus (HPV) test.   The physician reviewer found that although the patients cervical cancer screening began earlier than typically recommended due to a sexual assault, the provider in this case is following the established guidelines for follow-up of an ASC-US and HPV positive Pap smear in a 21-year-old.  The appropriate follow-up included the repeat Pap smear that was done on 7/17/15 given the previous abnormal findings on the Pap smear performed in 2014. For these reasons, the Pap smear performed on 7/17/15 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: Upheld

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. 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 the submitted documentation fails to demonstrate the medical necessity of the requested medication. Based on the growth chart provided, significant linear deceleration before the age of 14 is not confirmed. A growth velocity of 3.8 cm per year can be normal for a child who is not in puberty. Based on the testosterone level, the patient was probably pre-pubertal. There is a significant family history of delayed puberty in both parents, which also supports the diagnosis of constitutional delay of growth along with a history of multiple bone age studies with 1.5 years bone age delay. This patient has a mid-parental height that is 57, which is between the 10th and 25th percentile. Based on the last bone age and height from March 2019, and using an average bone age prediction, his estimated predicted adult height is 173 cm, which is within normal limits for an adult male. The patient had a bone age which was 15 years 6 months in March 2019. His bone age is likely closer to 16 years of age as of November 2019. This patient is not likely to benefit from growth hormone therapy at this time. Therefore, Humatrope 24 mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested reimbursement for PET scan performed on 8/19/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient was diagnosed with anal squamous cell carcinoma, and chemoradiation was planned.  Studies have shown that PET/CT alters management in a meaningful number of patients, sufficient enough to justify its use as part of staging investigations in locally advanced cases. PET/CT is recommended for both staging and radiotherapy planning in anal cancer, and alters nodal status in enough cases to justify routine use in anal squamous cell carcinoma staging. Guidelines from the National Comprehensive Cancer Network recommend consideration of PET/CT in patients with anal cancer with a biopsy positive for squamous cell carcinoma. In this case, PET/CT was indicated to evaluate for distant (higher-stage) disease before undergoing chemoradiation, given the potential that the imaging would alter her staging or nodal status and therefore change her treatment planning and disease outcome. Therefore, the PET scan performed on 8/19/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 



A 55-year-old male enrollee has requested reimbursement for durable medical equipment (special stockings, Sock Aid Nova and stocking donners) provided on 8/2/16. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees lymphedema of both lower extremities. The physician reviewer found that the durable medical equipment (special stockings, Sock Aid Nova and stocking donners) provided on 8/2/16 has been established as medically necessary for treatment of the patients medical condition. The patient presents with limb threatening lymphedema and venous stasis hypertension. This condition has caused ulcerations and cellulitis in the past. Prescription strength compression socks are the standard of care for patients with severely swollen lower extremities including, venous stasis hypertension, and lymphedema. These devices allow for mechanical compression of the lower extremity, facilitating movement of the fluid from the lower extremity proximal for distribution and resorption. This will in turn reduce the patients chance of ulceration, possible cellulitis, and possible further other complications. The compression socks along with the device to pull on the compression socks are medically necessary. The stocking donner is important as socks are difficult for people to place on themselves. It is an important part of the compliance of utilizing compression socks. Thus, the equipment at issue was medically necessary for the patients medical condition.  Therefore, the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 38-year-old female enrollee has requested authorization and coverage for matrix autologous chondrocyte implantation, up to three days in hospital stay and growth of cartilage from her knee. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees osteochondral defect. The physician reviewer found the request for matrix autologous chondrocyte implantation, up to three days in hospital stay and growth of cartilage from her knee are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Autologous chondrocyte implantation is a joint sparing/joint salvaging reconstructive procedure. The ankle joint is a complex joint with both dorsiflexion plantar flexion and rotational motion. Attempts to develop total ankle arthroplasty devices has been limited in meeting the design challenges posed by this joint. Kwak and colleagues reported on the long-term outcomes of patients who underwent autologous chondrocyte implantation of the talus after failed marrow stimulation techniques for osteochondral lesions of the talus. The authors concluded that autologous chondrocyte implantation of the talus yielded improvement in clinical parameters and was beneficial with enduring long term results in patients who had failed prior surgeries. Given the support in the peer-reviewed literature, the he requested services are 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 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: Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 7/8/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found the digital breast tomosynthesis performed on 7/8/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, the diagnostic procedure at issue 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 diagnostic procedure 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 Reviewer 

The patient is a 16-year-old transgender male. The patientas parent has requested authorization and coverage for a mastectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The World Professional Association for Transgender Health states, aChest surgery in female-to-male patient could be carried out [in minors]a preferably after ample time living in the desired gender role and after one year of testosterone treatment.a While length of time living stably in gender role and length of time on testosterone are not absolute requirements, they are met by this patient. This patient has lived in male role for three years and has been on testosterone for one year, having started testosterone in June 2019. Chest surgery in transmasculine minors has been demonstrated to be a safe and effective treatment for gender dysphoria. Olson-Kennedy and colleagues stated, aChest dysphoria was high among presurgical transmasculine youth, and surgical interventions positively affected both minors and young adults.a Therefore, the requested mastectomy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 7/14/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this patients case, her breasts were described as borderline heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 7/14/16 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: Overturned

Summary Reviewer 3

The patient is a 46-year-old female with a history of left groin pain related to a labral tear and pincer type femoroacetabular impingement. She tried nonoperative treatment including medications, physical therapy, rest, and avoidance of sports but her pain persisted.  She underwent an intra-articular injection of local anesthetic into the left hip with good pain relief. The magnetic resonance imaging (MRI) scan showed a complex labral tear of the acetabulum. She underwent arthroscopic management of femoroacetabular impingement with resection of a pincer lesion and debridement of the labrum. The intraoperative findings included mild degenerative changes of the left hip with a small area of fissuring and cartilage softening of the superior weight bearing dome of the acetabulum. There was also extensive degenerative labral tearing from the 10 oclock position to the 2 oclock position of the left hip without any gross labral detachment. The pincer lesion was seen between 11 and 12:00. No cam lesion was identified. The patient has requested for reimbursement for hip surgery performed on 1/31/17. The Health Insurer has denied this request on the basis that the services at issue were investigational for treatment of this patients medical condition. Surgical treatment of symptomatic femoroacetabular impingement aims to improve symptoms and potentially delay hip osteoarthritis and prevent the need for a possible total hip arthroplasty. Hip arthroscopy and open surgical hip dislocations are the two most common surgical approaches used for this condition. The arthroscopic procedure avoids some of the complications of open surgery but both approaches result in over 75% good to excellent results.  Femoroacetabular impingement may be of the cam or pincer type, as in this case, or it may be mixed.  Surgery is recommended when the degenerative changes are mild or absent, as in this patients case, with documented failure of conservative treatment for over six months. In this case, relief of pain with an intra-articular injection of the hip joint indicated the pain source. The imaging studies further confirmed the pathology.  As such, hip surgery was better than any conventional standard treatment. As indicated in the medical literature, the surgery is known to be beneficial and is not investigational. In light of the foregoing, hip surgery performed on 1/31/17 was likely to have been of greater benefit than the standard conventional options available for treatment of the patients medical condition. 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.