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

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. 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 the residential mental health services provided from 4/6/15 through 5/5/15 were medically necessary for treatment of the patients medical condition. Based on the additional documentation submitted for review, the patient demonstrated a complex illness burden that encompassed all elements of the biopsychosocial conceptualization which presented a challenging placement determination. In this case, the patient was isolative. She had not been employed in more than 20 years. She had no children. She had limited social support and was the primary care giver for her spouse who suffered from Parkinsons disease. Additionally, the patient had formidable, co-occurring mood and anxiety disorders. This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, even without the complication of pathological personality traits, are notoriously difficult to treat and in general have poor outcomes (Fava, et al). The patient remained symptomatic despite the delivery of multiple evidence-based interventions during the episode of illness. Based on the duration of symptoms, relevant clinical history, psychosocial factors and characterological influences, safe and effective care could not have been adequately provided in a less restrictive setting at the time. Thus, the residential mental health services provided from 4/6/15 through 5/5/15 was medically necessary for treatment of the patients behavioral health 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: Upheld

Summary Reviewer 2
A 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.  The physician reviewer found that the Life Vest was not likely to be more beneficial for treatment of this patients condition compared to standard available therapies. The patient has newly diagnosed dilated non-ischemic cardiomyopathy. The Life Vest wearable defibrillator is generally accepted for patients who meet criteria for implantable cardioverter defibrillator (ICD) placement but have a temporary contraindication to device placement, such as infection. There is a lack of randomized, controlled trials supporting use of the wearable defibrillator for patients with a new diagnosis of dilated cardiomyopathy as opposed to optimal medical therapy alone. Based on the registry data by Chung and colleagues, there does not appear to be a significant benefit of the wearable defibrillator for this patients diagnosis. In the registry, there was a very low incidence of appropriate therapies for ventricular arrhythmias for this group of patients. It is recommended that the patient have a trial of optimal medical therapy. Consistent with these findings, the Life Vest provided on 5/23/14 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, I have determined 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: Upheld

Summary Reviewer 2

A 53-year-old female enrollee has requested reimbursement for gene testing performed on 11/15/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma.The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines note while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low-risk versus high-risk for metastasis, routine (baseline) prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The medical evidence does not support the services at issue in this clinical setting. In sum, gene testing performed on 11/15/16 was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. 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 that in general, PET/CT is useful for staging a known malignancy. If indeed the final pathology was a tumor of renal origin, it is not clear the reason such a tumor was not seen on conventional imaging which would usually have been the case. There is a lack of support for the services at issue in this clinical setting. 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 

A 64-year-old male enrollee has requested authorization and coverage for functional electrical stimulation cycle ergometer. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees tetraplegia. The physician reviewer found that the patient has a spinal cord injury that results in reduced mobility and reduced ability to engage in exercise. Functional electrical stimulation cycling has been developed as a means to stimulate muscle activity in paralyzed limbs to reproduce physiological effects of exercise. The literature has explored the effects of functional electrical stimulation cycling to determine if this artificial form of exercise has clinical benefit. The net weight of evidence has been positive, showing that functional electrical stimulation cycling promotes improved health status in people with spinal cord injury. There is sufficient support for the requested device in this clinical setting. Thus, the requested functional electrical stimulation cycle ergometer is medically necessary in this patients case. Therefore, the requested device is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for autonomic nerve testing performed on 9/03/15. 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 that the medical records provided for review does not support the autonomic nerve testing performed on 9/03/15.  The available medical records do not indicate any focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function.  The records do not report by history the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes.  There is no indication of neuropathic pain being reported in terms of having hypersensitivity, allodynia.  Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms. The available medical records provided for review does not support the presence of subjective symptoms consistent with autonomic nervous system abnormality or indicate objective findings on physical examination which support autonomic nervous system dysfunction.  In sum, the superior efficacy of autonomic nerve testing performed on 9/03/15 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: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 46-year-old female with chronic pain at the hip joint. The patients pain has reportedly been present since 2011, treated with physical therapy, steroid injections and arthroscopic labral surgeries. A diagnosis of right labral tear was made in 2011. Arthroscopic surgery was recommended in an attempt to repair the labrum. There were multiple complications following this surgery with a total of four surgical procedures in 13 months. Pain in the hip joint continued. In 2015, a fifth surgical procedure was performed with initial improvement in symptoms followed by recurrence in symptoms. X-rays on 12/8/16 demonstrated moderate medial femoral acetabular osteoarthritis with joint space narrowing as well as moderate osteoarthritis with joint space narrowing. The patient has requested authorization and coverage for AmnioFix injection. The Health Insurer has denied this request indicating that the requested service is considered investigational. AmnioFix is described as a composite amniotic membrane substance containing growth factors unique to placental tissue. AmnioFix has been utilized in the treatment of ocular burns, conjunctival injuries, and in sheet form for wound care. AmnioFix injections have been recommended in a number of orthopedic conditions including plantar fasciitis and Achilles tendonitis. In this particular patient, anatomical changes are likely to have already occurred within the labrum and the patient has joint space narrowing such that molecular level interventions are not likely to have a positive effect. Given these findings, the requested AmnioFix injection 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 service 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 2

A 25-year-old male enrollee has requested authorization and coverage for the LINX Reflux Management System.  The Health Plan 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 in this case, the patient presents with non-acid dyspepsia as well as GERD, based on pH recording. The records demonstrate that the patient has benefited to a significant degree from acid suppression treatment to the same extent that his pH study showed correlation of acid reflux events and heartburn. Thus, the patient cannot be considered medically refractory to acid blocker drugs, and does not meet the U.S. Food and Drug Administration (FDA) indication for implantation of the LINX device. In addition, the, implantation of LINX in this clinical setting must be approached with caution given the patients documented complaint of dysphagia. For the reasons provided, the request for the LINX Reflux Management System 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 60-year-old female enrollee has requested reimbursement for the gene test (gene expression profiling) CPT 84999 performed on 12/29/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that 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 literature for the testing at issue in this clinical setting. According to the results of analysis of patients melanoma performed with DecisionDx melanoma, the tumor was classified as Class 1B with a low risk of near-term (within five years) metastatic disease, such as 90% metastasis free rate. According to the standard analysis of such risk, the lesions of 1-2 mm depth have a risk of 80-96%. Although DecisionDx melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. Therefore, the gene test (gene expression profiling) CPT 84999 performed on 12/29/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a five-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) therapy provided from 6/5/15 through 12/3/15. 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 autism spectrum disorder (ASD). The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Reichow and colleagues performed a review showing that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. Based on the documentation submitted for review, the patient presents with symptoms consistent with autism. Maladaptive behaviors including aggression and tantrums are difficult to treat with other interventions. The research shows that although medications including Risperdal can reduce some of the aggression in children with ASD it does not treat the core symptoms and does not provide long term benefits. Matson and Jang performed a literature review on treating aggression in persons with ASD and found that the most effective interventions were behavioral interventions including ABA therapy. Based on the support in the peer-reviewed literature and the documented regression in behaviors with a reduction of hours, the request for 30 hours per week of ABA was and is medically necessary for treatment of the patients medical condition. 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 9/22/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. 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 1 
 
The parent of a six-year-old male insured has requested reimbursement for Coronavirus COVID-
19 (SARS-CoV-2) respiratory panel performed on 11/8/22. The Health Plan has denied this request 
indicating that the requested services are considered investigational for evaluation of the insureds 
respiratory illness with concern for SARS-CoV-2 infection. The physician reviewer found that the 
use of respiratory panels to diagnose the cause of respiratory symptoms remains of unclear value 
when  compared  to  other  tests  including  COVID-19  polymerase  chain  reaction  (PCR).  The 
recommendations in the medical literature support testing when a patient is immunocompromised, 
at high risk of complications from the infection, and when testing could be used to direct therapy. 
This patients records fail to adequately document that the patient was immunocompromised, at 
high risk of complications from the infection, or that testing was being performed to direct therapy. 
As noted by Calderaro and colleagues, The implementation of molecular methods with syndromic 
panels has the potential to be a powerful decision-making tool for patient management despite 
requiring appropriate use of the test in different patient populations. However, there is a lack of 
data to support a clinical indication for the Coronavirus COVID-19 (SARS-CoV-2) respiratory 
panel for diagnosis of this patient in lieu of COVID-19 PCR testing. All told, the Coronavirus 
COVID-19 (SARS-CoV-2) respiratory panel performed on 11/8/22 was not likely to be more 
beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 16-month-old male who was born by Cesarean section at 32 weeks 3 days gestation. The patients parent has requested reimbursement for physical therapy and speech therapy services provided from 7/22/20 through 8/24/20. 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 physician reviewer found This patient was born prematurely, at 32 weeks 3 days gestation. He spent four weeks in the NICU, and required a feeding tube. He has documented developmental delays, including gross motor delays, apraxia, poor emotional regulation, and feeding difficulties. Spittle and colleagues noted, Infants born preterm are at increased risk of developing cognitive and motor impairment compared with infants born at term. Early developmental interventions have been provided in the clinical setting with the aim of improving overall functional outcomes for these infants." Woodward and colleagues reported that infants born before 34 weeks of gestation have three times the risk of impairments in multiple developmental domains compared with term infants. Bui and colleagues stated, Preterm children should be screened regularly for developmental delay, and parents of preterm infants should be counseled about the options of early intervention programs, and their potential positive impact on development. The medical evidence supports the services at issue in this clinical setting. Therefore, physical therapy and speech therapy services provided from 7/22/20 through 8/24/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 55-year-old female enrollee has requested authorization and coverage for Sirturo. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees mycobacterium avium-intracellulare complex (MAC). The physician reviewer found the submitted documentation fails to demonstrate that the patients medical condition meets medical necessity criteria for the requested medication, Sirturo. Sirturo is U.S. Food and Drug Administration (FDA) approved for treatment of drug resistant tuberculosis (TB) resistant to INH and Rifampin; the patients records do not show that she has drug resistant TB. Furthermore, Sirturo has potential adverse cardiac effects (Sirturo Prescribing Information). Moreover, medical studies evaluating the use of Sirturo for treatment of MAC are limited. A study by Philley and colleagues involving patients with atypical mycobacteria who were treated with Sirturo included only 10 patients, and was not blinded, randomized or controlled. Finally, the record indicates that the patients MAC appears stable on CT scan. All told, the requested medication is not medically necessary for treatment of the patients medical condition. Based on the submitted documentation and per accepted clinical guidelines, 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 2

The patient is a 58-year-old female with a history of gastroesophageal reflux disease (GERD). Evaluation has included esophagogastroduodenoscopy (EGD) in 2017 with a small hiatal hernia, irregular Z-line and histologically mild acute and chronic esophagitis, and minimal to mild Helicobacter pylori-negative gastritis. In 2017, pH testing performed off acid blocker therapy identified a composite DeMeester score of 39.7 and zero correlation of acid reflux events with heartburn. The patient has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational. The LINX device received U.S. Food and Drug Administration (FDA) premarketing for patients with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. This patient has GERD based on pH recording and radiographic criteria. However, she does not have evidence of advanced esophagitis nor was there correlation noted between acid reflux events and heartburn. Given that only 64% of patients achieved either normalization of or at least 50% reduction in esophageal acid exposure with LINX (1), this patients lack of correlation of symptoms with acid exposure does not support an indication for the requested procedure. Thus, the requested LINX procedure is not likely to be more beneficial for treatment of the enrollees medical condition than any available standard therapy.  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.