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

Summary Reviewer 

A 57-year-old male enrollee has requested reimbursement for magnetic resonance imaging (MRI) (code 73721) performed on 12/22/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees knee pain. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. MRI is the most optimal means to evaluate an internal derangement. Plain x-rays are of only limited value because the menisci and ligaments are not visible on plain x-rays. One can assess the degree of degenerative disease and whether there are any acute bony structural abnormalities, but this information is only of limited interest in this patient. The initial x-rays did not demonstrate a fracture, and whether or not he has degenerative change has no bearing. Some patients with no degenerative disease have grossly abnormal menisci, and conversely, there are patients who have gross degenerative joint disease but relatively intact menisci. In a typical patient without trauma, conservative management may be appropriate prior to considering an MRI. However, this patient had an acute traumatic event. Subsequently, the patients symptoms worsened to the point where he had difficulty bearing weight. In this patients case, there was an indication for subsequent cross-sectional imaging following trauma and a negative initial plain x-ray. In sum, considering the worsening symptoms, and the likelihood of associated ligamentous injuries, the MRI was the best means for further evaluation. Thus, MRI (code 73721) performed on 12/22/17 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 24-year-old male with a history of persistent depressive disorder and generalized anxiety disorder. The patient reported that he has been depressed since middle school. He reported that he was consuming alcohol as a coping method. The records indicate that he was anxious, depressed, and irritable. The patient was admitted to an intensive outpatient program and was treated with psychotherapy and psychopharmacology. The patient requested reimbursement for mental health intensive outpatient services provided from 8/11/16 through 12/31/16. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The Level of Care Utilization System (LOCUS) is an accepted, national standard for determining the appropriate level of care for adults. During the dates of service in dispute, in terms of risk of harm, the records support a score of 2. There was no documentation of prior suicide attempts or current suicidal or homicidal ideation. The patient did have passive suicidal ideation. With regards to functional status, the records support a score of 3. The patient had moderate impairment. It appeared that the patient was unemployed. In terms of medical/addictive/psychiatric comorbidity, the records support a score of 3. The patient has no serious medical problems. However, he had been overusing alcohol. He reports having persistent depression since middle school. With regards to recovery environment, the records support a score of 2. The patient had a mildly stressful environment. He had pressure from his family regarding expectations to perform well in school. In terms of level of support, the records support a score of 2. The patients parents were supportive of the patient. With regards to treatment history, the records support a score of 2. It does not appear that the patient participated in extensive outpatient treatment prior to the intensive outpatient program admission. In terms of engagement and recovery status, the records support a score of 2. The patient was attentive and engaged during treatment. The patient appeared motivated for change and was compliant with medication. Therefore, the records support a composite score of 16.  Based on these criteria, the patient met criteria for routine outpatient services. The patient could have been treated through outpatient psychopharmacology and routine outpatient individual and group therapy. The patients alcohol use could have been treated through a sober living environment along with Alcoholics Anonymous groups. The patient continued to require treatment for his persistent depressive disorder and anxiety, but this could have been done in a less restrictive environment. Thus, mental health intensive outpatient services provided from 8/11/16 through 12/31/16 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: Overturned

Summary Reviewer 3

A 50-year-old female enrollee has requested reimbursement for Afirma gene testing performed on 7/22/14. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Over the last few years gene testing analysis has become standard of care for analyzing thyroid nodules with a cytologic diagnosis of atypia of undetermined significance or follicular lesion of undetermined significance. This patient is precisely the type of patient that would benefit from this type of analysis. Therefore, the Afirma gene testing performed on 7/22/14 was likely to be more beneficial than other modalities. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 33-year-old female enrollee has requested reimbursement for gene testing (BRAF mutation analysis) provided on 11/19/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees papillary thyroid carcinoma. The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is insufficient support in the peer-reviewed medical literature for the testing at issue in this clinical setting. The National Comprehensive Cancer Network (NCCN) guidelines classify molecular profile testing as category 2B, based upon lower level evidence. Given the lack of sufficient support per national guidelines, the gene testing (BRAF mutation analysis) provided on 11/19/15 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 41-year-old female enrollee has requested authorization and coverage for Xeljanz. 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 current medical evidence supports the requested medication in this clinical setting. This patient has been diagnosed with rheumatoid arthritis. In addition to having failed methotrexate, Orencia and Actemra, the patient also failed a reasonable trial of two anti-tumor necrosis factor agents, Cimzia and Enbrel. The current literature supports the use of a drug with a different mechanism of action than anti-tumor necrosis factor agents. Per Emory and colleagues, if more than one tumor necrosis factor (TNF) inhibitor provides inadequate responses and/or similar tolerability issues, switching to a different class of agent may provide a more effective option. Gottenberg and colleagues noted that among patients with rheumatoid arthritis previously treated with anti-TNF drugs but with inadequate primary response, a non-TNF biologic agent was more effective in achieving a good or moderate disease activity response at 24 weeks than was the second anti-TNF medication. Therefore, Xeljanz is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 63-year-old female enrollee has requested authorization and coverage for dental services. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the treatment of the enrollees dental condition. The physician reviewer found that treatment for accidental injury is medically necessary when treatment is required due to accidental damage, with coverage for crowns when the service is the only clinically acceptable treatment alternative. Clinical records from prior to the accident and immediately following the accident do not demonstrate significant damage to the teeth, with the exception of the tooth fracture on number 7, which clinical records would indicate could be repaired successfully with a conventional bonded restoration. With a history of periodontal disease, the literature supports that even when treated and stabilized, mobility would be expected due to the loss of supporting alveolar bone. Aesthetic concerns include the existence of super eruption of tooth number 8 related to the patients history of periodontal disease, as well as rotations and malocclusion existing at the time of the accident.  These findings would demonstrate that the treatment requested is, to a significant extent, to address structural and aesthetic issues related to existing periodontal disease and malocclusion and not in treatment of injury related to the patients fall, as the only substantial damage related to the fall was the incisal fracture of number 7 noted above. Therefore, the requested dental services are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 52-year-old male enrollee has requested reimbursement for gene testing (gene expression profiling) performed on 10/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch, with some minor updates. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based upon the risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma testing class and risk of recurrence in patients undergoing sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not clear that the DecisionDx-Melanoma testing assay can be used to make clinical decisions. In sum, gene testing (gene expression profiling) performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
A 30-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg tablet. 
The Health Insurer has denied this request and reported that the requested medication is 
investigational for the treatment of the enrollees medical condition. The physician reviewer 
found that available treatment options for alopecia areata are quite limited. This is especially 
true for diffuse/multifocal involvement, where standard therapies such as topical steroids, 
intralesional kenalog, contact immunotherapy and conventional immunosuppressants are often 
less than satisfactory and associated with side effects. There is substantial clinical evidence to  support the use of oral Janus kinase inhibitors such as tofacitinib for alopecia areata (including 
from clinical trials). In one open label pilot study by Jabbari and colleagues, eight of 12 patients 
demonstrated greater than 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) 
scoring. Liu and colleagues performed a retrospective study which consisted of patients age 18 
years or older with alopecia areata with at least 40% scalp hair loss treated with tofacitinib. The 
authors found that 77% achieved a clinical response. There have been minimal adverse effects 
reported to date. Moreover, these results are better than what has been reported for contact 
immunotherapy and systemic steroids (which have considerable short-term and long-term side 
effects). Therefore, Xeljanz 5 mg tablet is likely to be more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for thoracic spine magnetic resonance imaging (MRI) performed on 6/27/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees thoracic pain. The physician reviewer found that presently, there are no discrete guidelines for the management and evaluation of thoracic pain. The current practice guidelines are based upon the guidelines for low back pain. According the American College of Radiology appropriateness criteria for the evaluation of back pain, in a patient with sub-acute or chronic back pain who is a surgical candidate with persistent symptoms after four to six weeks of conservative management, MRI is considered usually appropriate. Imaging after conservative treatment could affect patient management if intervention is pursued. MRI can demonstrate disc disease and central canal stenosis among other findings, which may be the cause of the patients symptoms and may prompt intervention. First-line evaluation and treatment of back pain remains conservative, utilizing NSAIDS, physical therapy, as well as activity modification. If the patient is a candidate for intervention, and the pain persists despite four to six weeks of these measures, then MRI imaging may be appropriate. In this case, there is documentation of conservative evaluation and treatment for at least four weeks. Thus, MRI was appropriate as the next diagnostic step. In sum, thoracic spine MRI performed on 6/27/18 was medically necessary for the evaluation of this patient. Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 36-year-old female enrollee has requested reimbursement for AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who underwent open reduction and internal fixation. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The medical evidence has not demonstrated that AmnioFix graft was likely to be more effective than any other available standard therapy.  Further study is warranted to fully understand the efficacy of this treatment method. In sum, AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18 was not likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the treatment of autonomic neuropathy can often involve multidisciplinary strategies, both from cardiovascular medicine as well as neurology. This patient has been treated with a variety of modalities, including beta-blocker therapy, fludrocortisone and pyridostigmine, but has some persistent symptomatology. There is the additional factor that there may be comorbidities to suggest autoimmune disorder as well. However, the use of intravenous immunoglobulin to treat autonomic dysfunction remains investigational. The study by Schofield is retrospective and only included 38 patients. There is a lack of support for the requested medication in this clinical setting. Therefore, Octagam infusions are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 46-year-old female insured has requested authorization and coverage for lymphedema surgery 
and two inpatient bed days. The Health Insurer has denied this request indicating that the requested 
services  are  considered  investigational  for  treatment  of  the  insureds  lymphedema.  
The physician reviewer found that lymphedema surgery has slowly improved over time and has 
become more mainstream with the improvement in microsurgery techniques. With advances in 
super-microsurgery as well as findings from breakthrough studies, the surgical treatment of 
lymphedema has become widely accepted and is considered the gold standard for treatment of this 
disease process (Chang, et al.; Schaverien, et al.). Once the diagnosis is confirmed with tests, such 
as this patients evaluation with lymphoscintigraphy, treatment options include compression 
garments and or surgery, which have been demonstrated to be effective modalities to help alleviate 
symptoms in patients with lymphedema (Brown, et al.). Surgical options are based on the stage of 
the disease. Lymphovenous bypass is a treatment option described for her stage of disease. Based 
on the review of this case, the patient underwent evaluation and was diagnosed with lymphedema. 
The patient has undergone surgery on the left side twice. She appears to have recovered well after 
surgery and now seeks treatment for the other affected side. Given the patients history and the 
current literature, the requested lymphedema surgery and a two day hospital stay is likely to be 
significantly more beneficial for treatment of the patient than other available therapies. In addition, 
she has proven by her own medical history that this treatment has been successful for her left leg. 
All told, the requested lymphedema surgery and two inpatient bed days is likely to be more 
beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 22-year-old male has requested reimbursement for Prometheus Anser IFX testing performed on 8/30/15.  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 there is sufficient support for the services at issue in this clinical setting.  With respect to maintenance of healing of perianal disease in Crohns disease, Remicade has the strongest evidence to support its use.  Therefore, it is critical to identify whether the patient is developing antibodies or a sub-therapeutic levels of infliximab as discontinuation or an increase in dose may be necessary depending on the results.  In sum, Prometheus Anser IFX testing performed on 8/30/15 was likely to have been superior over 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 54-year-old male enrollee has requested reimbursement for inpatient admission on 6/3/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees lower abdominal pain. The physician reviewer found that impatient care is medically necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated and treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition and could have been treated at an observational level of care.  He was tolerating oral fluids and his pain was well controlled. The patient remained hemodynamically stable without a need for any urgent procedures. Thus, the patient could have been treated at a lower level of care. As such, the inpatient admission on 6/3/16 was not medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 42-year-old male enrollee has requested reimbursement for substance abuse treatment provided form 6/25/19 through 7/02/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Per the American Society of Addiction Medicine (ASAM) criteria, substance abuse residential treatment was medically necessary. The records document longstanding heavy alcohol use which posed a serious danger to his liver and brain health. He reported a history of persisting anxiety and depression since age ten. The clinical notes documented poor insight and judgment, and he presented with no clear plan on how to change. The patient had multiple prior relapses, including a relapse just after his discharge from admission 10 days prior to the admission at issue. The records noted limited support, marital separation, and he associated with others who consumed alcohol. Patients requires safe and stable living environments in order to develop their recovery skills. Given the severity of the patients illness, residential treatment was in accordance with generally accepted standards of medical practice and was clinically appropriate for the patients illness. Therefore, substance abuse residential treatment provided from 6/25/19 through 7/02/19 was medically necessary for the treatment of this patient.