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

Summary Reviewer 3


A 50-year-old male has requested authorization and coverage for the LINX Reflux Management System.  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 there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  Sheu and Rattner concluded that the long-term safety and efficacy of LINX remains to be determined.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval.  Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication.  Thus, the LINX Reflux Management System is not likely to be more effective than other treatment alternatives.  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: Overturned

Summary Reviewer 1


A 42-year-old male enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back and left lower extremity pain.   The physician reviewer found according to the providers notes, the patient previously underwent lumbar medial branch blocks and lumbar RFA in the past. The records indicate that the patient underwent lumbar medial branch blocks successfully and then underwent lumbar RFA. The prior RFA provided over one year of pain relief. Given this patients treatment history, repeated lumbar medial branch blocks are not needed prior to repeat RFA. Therefore, the requested RFA 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, 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 48-year-old female enrollee has requested authorization and coverage for reconstructive lymphedema surgeries and one (1) inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrolleeas condition than any available standard therapy. The physician reviewer found that 
there is sufficient support for the requested services in this clinical setting. Chang and colleagues noted, aMany studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transfer.a Beederman and colleagues followed 274 patient and reported, aPatients with secondary upper or lower extremity lymphedema who undergo vascularized lymph node transplant/lymphovenous bypass demonstrate improved functional status and reduced affected limb volumes postoperatively. Patients with upper extremity lymphedema appear to have a more substantial reduction in limb volume differential compared to lower extremity lymphedema patients.a Coriddi and colleagues noted, aPhysiologic surgical treatment of lymphedema results in improved quality of life outcomes in most patients.a Based on the literature, lymphaticovenous anastomosis and vascularized lymph node transfer offer benefits to patients who have undergone extensive attempts at decongestive therapy and still have significant lymphedema. The patient is noted to be compliant with her therapy. Therefore, reconstructive lymphedema surgeries and one (1) inpatient bed day are likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 42-year-old male enrollee has requested reimbursement for decompression procedure performed on 10/5/15. The Health Insurer has denied this request indicating that the procedure at issue is considered investigational for treatment of the enrollees occipital neuralgia.  The physician reviewer found that the procedure (neurolysis) at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of large, scientific, randomized, controlled studies showing the long-term effectiveness of neurolysis in this clinical setting. There are some promising studies supporting neurolysis of the greater occipital nerve (Ducic, et al; Acar, et al). However, these studies are primarily retrospective, small, uncontrolled studies with only short-term follow up. Given the lack of sufficient support in the peer-reviewed literature, the decompression procedure performed on 10/5/15 has not been established as 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 procedure 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: Upheld

Summary Reviewer 2

A 24-year-old female enrollee has requested reimbursement for 83993 (fecal calprotectin) provided on 1/30/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that persistent disease activity is associated with a poor prognosis in inflammatory bowel disease. Therefore, monitoring of patients with intent to suppress subclinical inflammation has emerged as a reasonable community-standard treatment goal. As endoscopic monitoring is invasive, identification of valid markers of disease activity has been a priority. Fecal calprotectin testing is commonly used in clinical practice to differentiate between non-organic and inflammatory intestinal disorders, especially to identify inflammatory bowel disease. Fecal calprotectin may also be useful to monitor patients with inflammatory bowel disease under treatment and to predict the risk of recurrence of active disease prior to clinical relapse. In this patients case, the provider noted that fecal calprotectin testing was recommended to distinguish inflammatory from noninflammatory diarrhea. However, prior stool and imaging studies were negative, and inflammatory bowel disease was an unlikely possibility based on the history. While fecal calprotectin as commonly employed in clinical practice may have value in irritable bowel disease patients, or even in cases of diagnostic uncertainty, this testing was not supported in this patients case. In sum, the superior efficacy of 83993 (fecal calprotectin) provided on 1/30/18 has not been established. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 15-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health intensive outpatient program treatment provided from 9/22/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that mental health intensive outpatient program treatment provided from 9/22/15 forward was and is medically necessary for treatment of the patients medical condition. According to the American Psychiatric Association guidelines services available for the treatment of eating disorders can range from intensive inpatient settings to residential and partial hospitalization programs to varying levels of outpatient care. In this case, the patient has been diagnosed with major depressive disorder, recurrent, generalized anxiety disorder, bulimia nervosa in partial remission and obsessive compulsive disorder and has completed a month long residential DBT program due to the long history of self-injurious behavior and suicide attempts. She engaged in the treatment however she still continues to have significant symptoms of depression and anxiety. Per the therapy note dated 9/28/15 the patient reported feeling an increase of anxiety due to multiple transitions over the last year. Based on the documentation submitted for review, the request for intensive outpatient program treatment provided from 9/22/15 forward was and is medically necessary as this patient continues to have significant symptoms of depression and anxiety. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 20-year-old female enrollee has requested reimbursement for acute inpatient psychiatric treatment from 9/15/15 through 11/8/15. 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 that there is a lack of support for the services at issue in this clinical setting. By 9/15/15, the patient was not a danger to herself or others. She was not aggressive or violent.   She denied and did not demonstrate self-harm or eating disorder urges.   She was cognitively intact and she was not gravely disabled. She was cooperative and participating in her treatment plan.  Through the balance of her stay she remained overall euthymic with bright affect.  Although nursing assessments reported her as delusional, this was not described and no auditory or visual hallucinations were endorsed. For most of her hospitalization leading up to the dates in dispute, she was described as euthymic with congruent affect. Her behavior had stabilized and there was no evidence that stepping her down to a lower level of care would have resulted in immediate acute inpatient re-hospitalization.  She tolerated medication changes without incident.  At this point, she did not require 24-hour a day, seven days a week supervision. She could have safely continued treatment at an ambulatory level of care such as partial hospitalization program. As such, acute inpatient psychiatric treatment services from 9/15/15 through 11/8/15, were not medically necessary. Therefore, for the reasons stated above, 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

A 66-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 8/10/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung adenocarcinoma. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection beyond standard testing, such as EGFR. The National Comprehensive Cancer Network guidelines advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. In sum, Guardant360 testing performed on 8/10/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 




The parent of an 11-year-old female enrollee has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the requested medication is not medically necessary for treatment of the patients medical condition. There is insufficient medical information in the submitted material to support medical necessity of GH treatment. If the patients diagnosis is intrauterine growth retardation with failure to catch up in height by age three, then data on birth weight and height, as well as a longitudinal growth chart from infancy until the start date of GH therapy should be provided. Based on the growth chart included for review, the patients height was within normal limits for age at age seven years from the 25th to 50th percentile. Thus, there is a lack of evidence that she had short stature warranting GH treatment at that time, although it is unclear if GH was started prior to that time and if there was a prior fall-off in growth. Additional information documenting abnormal results on provocative GH testing, pre-treatment height and weight, complete longitudinal growth curve dating back to the time before GH therapy was initiated, pre-treatment insulin-like growth factor-1 (IGF-1) level  and results of other tests to rule out systemic causes of poor growth, were not provided to support the resumption of GH. As such, Nutropin AQ Nuspin has not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 53-year-old male enrollee has requested reimbursement for the bronchial thermoplasty provided from 1/21/15 through 4/8/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found that three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Cox and colleagues reported on the AIR trial, which examined 112 patients with moderate-to-severe asthma and demonstrated improved control over the course of the one year follow-up. Pavord and colleagues conducted the RISA study and examined the safety of thermoplasty. The authors found short-term worsening in symptoms, but evidence of improved long-term control of asthma. Castro and colleagues reported on the AIR2 trial, which compared thermoplasty with a sham procedure and followed the patients for 12 months as well. The patients in this study had milder asthma when compared with the AIR and RISA study, with far fewer on oral corticosteroids. Several years ago, two follow-up studies were performed establishing a long-term improvement in asthma control over five years after the bronchial thermoplasty was performed. A follow-up of 14 patients in the RISA trial by Pavord and colleagues found a decrease in emergency department visits and hospitalizations in each year after bronchial thermoplasty and no change in lung function. The follow-up of the AIR2 trial from Wechsler and colleagues showed sustained improvement in 162 of the 190 patients followed for the complete five years. As with the RISA data, this was manifested with fewer emergency department visits and hospital admissions with stable spirometry and a decrease in mean inhaled steroid use over that period of time. 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 56-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/21/15.  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 medical literature supports the services at issue in this patients case.  According to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  All told, breast tomosynthesis performed on 7/21/15 was likely to have been of greater benefit than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for platelet-rich plasma injections performed on 3/11/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees plantar fasciitis. The physician reviewer found that the current medical evidence has not established the superior efficacy of the services at issue.  The literature suggests that platelet-rich plasma injections are as effective as corticosteroids.  Per Gogna and colleagues, when compared to low dose radiation, platelet-rich plasma injections were only seen to be as good.  Platelet-rich plasma injections may be appropriate when corticosteroid and electric shock wave treatment therapies are performed and failed.  Thus, platelet-rich plasma injections performed on 3/11/16 were not likely to have been more efficacious than other 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 19-year-old female with anorexia nervosa, post-traumatic stress disorder, major depressive disorder, and generalized anxiety disorder. She was admitted to a residential treatment center on 12/23/19. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. With regards to risk of harm, the records support a score of 4. The records noted a past history of multiple suicide attempts, and she expressed suicidal ideation at the residential treatment center. In terms of functional status, the records support a score of 3. The records noted 
moderate impairment due to troubled relationships with parents and lack of employment or school attendance prior to admission. With regard to comorbidity, the records support a score of 3 due to the physical manifestations of anorexia nervosa, including low weight and laboratory abnormalities, co-occurring with post-traumatic stress disorder, depression, and anxiety symptoms. In terms of level of stress of the recovery environment, the records support a score of 3 due to discord with parents and recent transition back to the United States after a year of living abroad. With regard to level of support of the recovery environment, the records support a score of 3 due to parents ambivalence toward participating in treatment and lack of recent contact with the patient. In terms of treatment and recovery history, the records support a score of 4 due to the persistence of symptoms despite prior extensive treatment. With regard to engagement and recovery status, the records support a score of 3 due to poor insight and limited judgment. Thus, the patient has a composite score of 23. In this case, the records support medically monitored residential services. Therefore, eating disorder residential treatment center services from 1/23/20 forward were and are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 53-year-old male has requested reimbursement for bronchial thermoplasty performed on 4/08/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence fails to demonstrate the medical necessity of the services at issue.  Bronchial thermoplasty is a procedure that uses a bronchoscope probe/catheter to provide thermal energy to the smooth muscle of the airway.  There are three bronchoscopic procedures.  The first procedure treats the right lower lobe.  The second procedure treats the left lower lobe, and the third bronchoscopic procedure is for both upper lobes.  The procedures are scheduled three weeks apart.  Bronchial thermoplasty is not generally accepted, standard of care for the treatment of asthma.  The appeal letter states the patient has a progressive decrease in the quality of life.  However, the available evidence does not demonstrate that bronchial thermoplasty would improve the long-term functional outcome of the patients condition.  All told, bronchial thermoplasty performed on 4/08/15 was 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: Upheld

Summary Reviewer 1 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that Temporomandibular joint disorders 
usually present with symptoms and signs such as pain, mandibular movement, dysfunction, or 
joint sounds. Bruxism is characterized by teeth grinding. Botulinum toxin A (Botox) is a biologic 
toxin which inhibits skeletal muscle through hindering the production of acetylcholine in the 
nerve endings. The use of Botox for treatment of temporomandibular joint disorders and bruxism 
is not consistent with U.S. Food and Drug Administration (FDA) indications. While there are 
reports of the clinical use of Botox for the treatment of temporomandibular joint disorders and 
bruxism, the clinical evidence in current medical literature is insufficient to demonstrate the 
clinical efficacy of Botox in the treatment of temporomandibular joint disorders and bruxism or 
that it is more beneficial than standard therapies including the use of occlusal devices, NSAIDs, 
and physical therapy. Therefore, Botox is not likely to be more beneficial for treatment of the 
patients condition than any available standard therapy.