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

Summary Reviewer 


A 21-year-old male enrollee has requested reimbursement for applied behavioral analysis (ABA) therapy provided from 1/13/17 through 7/12/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the autism spectrum disorder. The physician reviewer found the ABA therapy provided from 1/13/17 through 7/12/17 was medically necessary for treatment of the patients medical condition. ABA therapy is an evidence-based treatment that has proven benefit in the behavioral treatment of autism (Smith, et al). This patient has a diagnosis of autism and continues to have significant delays. The provider indicates that the patient has highly dangerous behaviors that include running off the sidewalk onto the street, crossing the street without scanning the surroundings, and self-harm behaviors. The patient is a safety risk both at home and in the community due to his behaviors. In addition, the ABA provider has documented goals, tracking progress, and the extent of parental involvement and training indicated to meet the patients behavioral deficits. For the above reasons, the ABA therapy provided from 1/13/17 through 7/12/17 was medically necessary for treatment of the patients medical condition. Therefore, 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 60-year-old female enrollee has requested reimbursement for collagen crosslinks laboratory tests performed on 1/2/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that osteoporosis is a condition of thinning of the bones which leads to increased risk of fracture. It is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy x-ray absorptiometry.  Bone mineral density (BMD) assessment, via a bone density test, is still the criterion standard for evaluation and diagnosis of osteoporosis.  However, because changes in bone mass and density in response to anti-resorptive therapy account for only a small portion of the predicted fracture risk reduction, markers of bone turnover (proteins and peptides, referred to as biochemical bone markers, that are released as a consequence of the physiological action of osteoblasts and osteoclasts) may be a useful adjunct in monitoring of osteoporotic patients treated with antiresorptive agents. Evidence suggests that biochemical markers could be useful in making therapeutic decisions because, in general, the higher the bone remodeling and bone loss rates, the greater the concentration of bone biochemical markers in blood or urine. These tests may also assist in identifying individuals with elevated bone resorption, who have osteoporosis in whom response to treatment is being monitored.  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: Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for a breast tomosynthesis that was performed on 10/29/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for purposes of the enrollees breast cancer screening.  The physician reviewer found 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 (CT) 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 particular patient, she has breasts that have been described as being heterogeneously dense.  Even though the patients mammogram has not changed since the last study, it is specifically these patients, who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  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 2


A 40-year-old female enrollee has requested reimbursement for the Genecept Assay provided by Genomind, Inc. on 2/24/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees major depressive disorder. The physician reviewer found that based on the review of the submitted documentation, Genecept Assay provided by Genomind, Inc. on 2/24/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Pharmacogenetic testing in psychiatry is a newly evolving field but large randomized controlled trials are needed to further substantiate the utility of genetic testing in this clinical setting. A review of the available literature regarding pharmacogenetic testing suggests that it has been studied that to the extent that genetic factors are associated with the efficacy, tolerability, and safety of different drugs, pharmacogenetic tests may be used to personalize medication treatments for an individual patient. However, pharmacogenetic tests, such as the Genecept Assay, have a lack of evidence to support their clinical validity or utility. Overall, there is a lack of large randomized controlled trials that conclude the efficacy of pharmacogenetic testing in psychiatry. For these reasons, the Genecept Assay provided by Genomind, Inc. on 2/24/16 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: Upheld

Summary Reviewer 1 
 
An 18-year-old male enrollee has requested reimbursement for outdoor behavioral health 
services provided from 11/03/20 through 12/31/20. The Health Insurer has denied this request 
and reported that the services at issue were investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that a number of studies have demonstrated 
that outdoor behavioral health (OBH) programs are associated with reduced frequency of 
substance use and improved interpersonal relationships. Gass and colleagues compared the 
effectiveness of three post-acute adolescent substance use situations: outdoor behavioral health 
program (OBH), treatment as usual, and no structured treatment. Results of the study found that 
in the OBH group, completion rates were higher, and the treatment outcomes were 424% better 
as measured by the Youth Outcome Questionnaire. Despite the reported positive benefits of 
OBH, the literature does not support claims that OBH is more effective than other therapies. 
There are very few studies which directly compare outcomes of OBH to other therapeutic 
interventions. Although OBH can be an effective treatment intervention for adolescent substance 
use and mental health disorders, there is no evidence to support the claim that it is superior to 
the standard of care. Although the OBH literature contains a number of studies that suggest that 
participants  show  some  level  of  improvement  on  behavioral  health  outcomes,  there  are 
considerable limitations in the research methodology used to examine these programs and the 
results are not conclusive. Most notably, there is a lack of randomized controlled trials or well-
designed cohort studies that would allow causal conclusions about the impact of OBH to be 
drawn. Review of studies did not reveal OBH to be better than standard treatment. Therefore, 
outdoor behavioral health services provided from 11/03/20 through 12/31/20 was not likely to 
have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 56-year-old male with a history of elevated prostate specific antigen (PSA) of 7.4 
ng/mL  and  prostate  cancer.  The  patient  was  evaluated  by  a  radiation  oncologist  who 
recommended combined short-term androgen deprivation therapy with proton beam radiation 
treatment. The Health Insurer has denied this request and reported that the services at issue are 
not medically necessary for the treatment of this patient. The physician reviewer found that the 
patients provider recommended a course of radiation therapy for the patients early stage 
prostate  cancer.  Per  the  National  Comprehensive  Cancer  Network  (NCCN)  guidelines,  the 
utilization of proton beam radiation therapy as a treatment modality is not supported for the 
routine treatment of patients with prostate cancer. Proton beam radiation therapy has unique 
properties compared to standard photon beam radiation therapy or x-ray beam radiation 
therapy in its ability to deposit radiation dose. However, there is a lack of data demonstrating 
that the use of proton beam radiation therapy will result in any significant improvement in clinical 
outcome (Royce and Efstathiou). Thus, proton beam radiation therapy is strongly indicated in 
settings where severe toxicities would result if normal tissue constraints cannot be met by 
photon beam. Additional studies have not demonstrated clinically significant improvements in 
survival or normal tissue toxicities over photon beam when treating prostate cancer (Royce, et 
al.). In addition, proton beam radiation therapy may be appropriate in cases of unusual anatomy 
or in cases of re-irradiation of adjacent tissues. On review of this patients records, there is a lack 
of documentation of unusual anatomy or previous radiation in the target area. Given these 
findings, the requested proton beam radiation therapy is not medically necessary for treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested authorization and coverage for speech therapy.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees speech misarticulations. The physician reviewer found that to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, school success, socialization, and behavior.  In particular, speech sound disorders not only greatly reduce intelligibility, but have also been associated with later reading disability.  Speech sound disorders refer to any combination of difficulties that impact speech intelligibility, including perception, motor production, and phonological representation of speech sounds and segments. Articulation disorders are those that impact the form of speech sounds and are associated with structural and motor-based problems.  Phonology disorders impact the way speech sounds function within a language.  Treatment approaches have traditionally focused on either articulation or phonology. Articulation approaches are typically selected if the problem is thought to be motor-based, and phonologic approaches tend to target specific sound error patterns.  The literature supports speech therapy intervention for young children with speech sound disorders.  In this patients case, the records document misarticulations negatively impacting his intelligibility, in addition to oral-lingual structural abnormalities and oral-motor deficiencies, all resulting in a speech sound/production disorder.  All told, the requested speech therapy is medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a 15-year-old male enrollee has requested reimbursement for quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19. 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 this patient demonstrated loss of response with breakthrough symptoms prior to his scheduled medication doses. Measurement of drug and antibody levels has now been incorporated into professional guidelines, which include recommendations for both proactive and reactive therapeutic drug monitoring. Expert consensus guidelines state that it is appropriate to order drug and antibody concentration testing for all anti-tumor necrosis factor medications, including infliximab, in patients with a confirmed secondary loss of response. Guidelines specifically focusing on the pediatric age range reflect the same conclusion. The studies by Afif and colleagues and Yanai and Hanauer indicate that measurement of infliximab levels and anti-infliximab (anti-chimeric) antibodies produces actionable data. Change of dose or drug based on these results improves response to treatment, as measured by clinical response. In clinical practice, infliximab levels and antibodies allow the provider to adjust or change biologic therapy with some objective determinants. Thus, quantification of therapeutic drug, not elsewhere specified and immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified, performed on 12/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 26-year-old male enrollee has requested reimbursement for cervical discography injection provided on 6/25/20. The Health Insurer indicates that the services at issue were investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found this case was previously reviewed, and additional records were submitted. These additional records fail to demonstrate the superior efficacy of the services at issue. Cervical discogram or provocative discography in general has been controversial. In this case, it was unlikely that multiple levels were the cause of discogenic neck pain with normal imaging studies and absent any disc herniations. The patient is status post anterior cervical discectomy and fusion in 2019, with no relief of symptoms and significant narcotics use. The level of evidence for provocative discography is low in this setting. Therefore, cervical discography injection provided on 6/25/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 46-year-old male has requested reimbursement for air ambulance transportation provided on 9/04/19. 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 Dr. Martin Andrew Donlan, a physiatrist with the Roger C. Pearce Rehabilitation Hospital in Greenville, South Carolina, was consulted to assess the patient on 8/26/19. The Roger C. Peace Hospital Rehabilitation Center is a 53-bed unit that specializes in caring for people with traumatic brain injury and other conditions. Dr. Donlan recommended that the patient would benefit from an acute, multidisciplinary inpatient rehabilitation program. His consultation note indicated, Discussed recommendations with patient and spouse and both are in preference of going back to home state of Pennsylvania to complete inpatient rehabilitation stay. The decision to transport the patient to University of Pittsburg Medical Center in Pittsburgh, Pennsylvania, was made by the patient and his spouse in order to be closer to home. University of Pittsburg Medical Center was not the closest facility capable of providing inpatient rehabilitation services. Such services were available at the Roger C. Peace Hospital Rehabilitation Center. Further, at the time of transport, the patients condition was not life-threatening. He was medically stable for discharge from the hospital to an inpatient rehabilitation facility. Criteria for emergent air ambulance transport were not met in this case. Therefore, air ambulance transportation provided on 9/04/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. 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 this patient has a low risk prostate cancer, and molecular profiling was considered for guiding therapy decision making. National Comprehensive Cancer Network guidelines recommend Oncotype DX tumor-based molecular assays post-biopsy for men with low or favorable intermediate risk disease. Retrospective studies have shown that molecular assays performed on prostate biopsy or radical prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy. Men with clinically localized disease may consider the use of tumor-based molecular assays.  It is considered a standard of care in guiding treatment decision making. In sum, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for Testim. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees low testosterone.  The physician reviewer found that on the presented clinical records submitted for review, Testim is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients testosterone levels are normal. There are no laboratory tests showing luteinizing hormone or follicle stimulation hormone levels. Furthermore, there is a lack of documentation demonstrating low bone mineral density, low libido or weight loss. Given the lack of support in the documentation provided, the request for Testim 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: Upheld

Summary Reviewer 1

A 45-year-old male enrollee has requested authorization and coverage for radiofrequency ablation. 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 enrollee's condition than any available standard therapy. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. Yang and colleagues performed a literature search for publications on the effectiveness of sacral lateral branch radiofrequency ablation for sacroiliac joint pain. The authors noted, aOne pragmatic study did not show any difference between radiofrequency ablation and control treatment consisting of a standardized exercise program for sacroiliac joint pain. However, recalculation of success rates according to intention to treat analysis demonstrates a significantly higher success rate associated with sacral lateral branch radiofrequency ablation and exercise compared with exercise alone.a However, the authors also indicated, aHeterogeneity in technology and technique call into question the generalizability of the current literature.a Furthermore, the authors noted, aEstablishing the prevalence of posterior sacroiliac joint pain with pain that is relieved by multisite, multi-depth blocks is essential to furthering our understanding of sacroiliac joint region pain and optimizing treatment. Randomized, placebo-controlled studies using multisite, multi-depth sacral lateral branch (SLB) blocks to enroll patients for sacral lateral branch radiofrequency ablation compared with sham treatments are needed to assess the efficacy of this procedure.a  In this case, the patient has a history of positive response to diagnostic procedure with no benefit from definitive procedure in both the lumbar spine for fusion as well as the spinal cord stimulator trial and implantation. The requested treatment is not superior to standard treatments. Therefore, the requested radiofrequency ablation is not likely to be more beneficial for treatment of the patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 23-year-old male enrollee has requested reimbursement for physical therapy performed from 7/14/15 through 10/31/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees chronic pelvic pain syndrome. The physician reviewer found the services at issue were not medically necessary for treatment of his medical condition. The standard for outpatient physical therapy in treatment of pelvic pain and urinary or defecatory dysfunction is through the use of various modalities and techniques which are utilized to decrease pain and to rehabilitate the intrinsic pelvic floor musculature and extrinsic musculature of the lumbosacral spine. These various modalities increase the patients awareness and voluntary control of these muscles, while educating the patient on proper bowel/bladder techniques and habits. The standard course of physical therapy would include an initial trial of eight treatments. If there was benefit to the patient, an additional 16 treatments could be considered. After the initial physical therapy, transition to an independent exercise program would be expected with a fading of skilled therapy treatments. If there was a lack of improvement, then a reevaluation in terms of reasonable therapy goals or consideration of further medical workup would be the expected management. In this case, the number of therapies that were provided from 7/14/15 through 10/31/15 exceeded the standard number of treatments. 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.