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

Summary Reviewer 

The patient is a 63-year-old female with a diagnosis of hereditary angioedema and monoclonal gammopathy of unknown significance (MGUS). Provider records indicate that patient has ongoing angioedema with up to three attacks per month. Hereditary angioedema (HAE) attacks have responded well to Firazyr, which is used as on demand therapy, but recovery time is prolonged up to two to three hours following an attack. The provider has recommended tranexamic acid 650 mg tablets/120 tablets for a 30 day supply (two tablets, twice per day, with 11 refills). The provider states that this specific dosage will be used as ongoing prophylactic therapy, and a trial of tranexamic acid has previously shown effectiveness for this patient. The patient has requested authorization and coverage for tranexamic acid 650 mg tablets/120 tablets for a 30 day supply (two tablets, twice per day, with 11 refills). The Health Insurer has denied this request indicating that the requested medication dosage is not medically necessary. Given this patients medical condition, the requested dosage of tranexamic acid meets the criteria for medical necessity to provide long-term prophylaxis for the treatment of hereditary angioedema. There is sufficient evidence to support the long-term prophylactic dosing of tranexamic acid at 650 mg twice daily, which would necessitate the quantity of 120 tablets for a 30 day supply. According to the current evidence-based literature, this dosing amount is within the standard of care for the use of tranexamic acid for the long-term prophylactic treatment of hereditary angioedema. Accordingly, the requested tranexamic acid 650 mg tablets/120 tablets for a 30 day supply (two tablets, twice per day, with 11 refills) is medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested medication dosage is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 28-year-old female enrollee has requested reimbursement for CPT code 92025 (computerized corneal topography, unilateral or bilateral, with interpretation and report) provided on 6/02/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this patients case.  The medical records document keratitis sicca and eyelid cellulitis.  The records indicate that the patient had ongoing ancillary testing with topography and tear osmolarity for management of dry eyes.  The current medical evidence suggests that tear osmolarity is appropriate to determine the effectiveness of dry eye treatments and progress.  However, serial corneal topography is not.  In sum, the services at issue were not likely to have been of greater benefit 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: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 62-year-old female with invasive urothelial carcinoma status post chemotherapy using Gem/Cisplatin followed by a radical cystectomy revealing a high grade T4NxMx yP2aypN2. The patient subsequently developed a right inguinal lymph node on 6/29/17 with pathology consistent with metastatic urothelial cancer, multiple retroperitoneal lymph nodes were subsequently documented and the patient was started on pembrolizumab. FoundationOne testing on 8/15/16 revealed multiple genomic alterations. The patient has requested reimbursement for the FoundationOne gene test provided on 8/15/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational.  In the peer-reviewed medical literature, FoundationOne testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of FoundationOne in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the FoundationOne test provided on 8/15/16 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: Overturned

Summary Reviewer 1

The patient is a 63-year-old male with a diagnosis of benign prostatic hyperplasia (BPH). Associated symptoms include frequency, dysuria, intermittent difficulty in urinary flow, and an elevated prostate-specific antigen (PSA) of 10. A computed tomography (CT) scan of the abdomen and pelvis dated 8/21/17 showed a large prostate, thick bladder with calculi, intermittent hematuria, large calcifications, and left low pole stone and bladder stone. On 8/24/17, he underwent a prostate biopsy and a cystolitholapaxy, which revealed an enlarged prostate with a volume of 45 mL, biopsy was negative, and the bladder was moderate to severely trabeculated with multiple saccules and small diverticula with a stone of 1.5 x 2.5 cm. The patient has requested authorization and coverage for a prostatic urethral lift implant. The Health Insurer has denied this request indicating that the requested surgical procedure is considered investigational. The prostatic UroLift system is a minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift system treatment is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. Compared with standard available alternatives, the prostatic UroLift system is minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. All told, the requested prostatic urethral lift implant 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 procedure is 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 55-year-old female who presented to her provider on 1/3/22. The records noted 
generalized abdominal pain, along with fibromyalgia, chronic low back pain, and migraines. The 
patient has requested authorization and coverage for Oxycontin (oxycodone HCL tablet ER 12 
hour deter 40 mg). The Health Plan has denied this request and reported the requested 
medication is not medically necessary for the treatment of this patient. This denial is the subject 
of this appeal and determination. The physician reviewer found that the submitted documentation 
supports the medical necessity of the requested medication. On determining when to initiate or 
continue opioids for chronic pain, Dowell and colleagues report, Nonpharmacologic therapy 
and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider 
opioid therapy only if expected benefits for both pain and function are anticipated to outweigh 
risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy 
and nonopioid pharmacologic therapy, as appropriate. The authors further note, Before starting 
opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, 
including realistic goals for pain and function, and should consider how opioid therapy will be 
discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if 
there is clinically meaningful improvement in pain and function that outweighs risks to patient 
safety. The Federation of State Medical Boards (FSMB) recommends prescribers use opioid 
therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, 
only when non-opioid and non-pharmacological options have not been effective. Maintain opioid 
dosage as low as possible and continue only if clear and objective outcomes are being met. 
Manchikanti and colleagues advise that providers establish appropriate physical diagnosis and 
psychological diagnosis if available, consider appropriate imaging, physical diagnosis, and 
psychological status to collaborate with subjective complaints, and establish medical necessity 
based on the average moderate-to-severe pain and/or disability. In this case, the patient has 
chronic pain involving  multiple areas, particularly in the abdomen and back. The patient is 
currently receiving specialty care from gastroenterology and neurology for pain management. 
She has been stable on Oxycontin with adequate pain control, prescribed by the same provider, 
without irregular urine toxicology screens, and with CURES reports consistent with therapy. The 
records did not document evidence of adverse drug reactions or aberrant behavior identified. 
Given that this patient is being treated in a manner consistent with current medical literature, the 
requested medication is medically indicated. Therefore, Oxycontin (oxycodone HCL tablet ER 
12 hour deter 40 mg) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 31-year-old male enrollee has requested reimbursement for the home sleep study provided from 9/20/15 through 9/22/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the services at issue. There was no clinical indication for the home sleep study for this patient. The patient had a normal Epworth Sleepiness score and thus did not have daytime hypersomnia. Hypersomnia is the cornerstone for a diagnosis of clinically significant sleep apnea. In addition, he was not overweight or obese. There was no witnessed apnea. There was no documented elevated Mallampati score. Moreover, snoring is not an indication for a sleep study. For the reasons stated, the home sleep study provided from 9/20/15 through 9/22/15 was not medically necessary for evaluation of the patients medical condition. Given the above reasons, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that the American Society of Colon and Rectal Surgeons guideline for the management of hemorrhoids describes Doppler guided hemorrhoidectomy as an effective surgical intervention for patients that have failed medical management and office-based procedures (Davis, et al). In the peer-reviewed medical literature, Ratto and colleagues performed a multicenter trial of transarterial hemorrhoidal dearterialization performed in 803 patients with symptomatic grade II, III, or IV hemorrhoids. The authors noted that the overall success rate was 91%, with recurrence in 9%. Based on these results, the authors concluded that transarterial hemorrhoidal dearterialization is a safe and effective treatment for patients with symptomatic grade II, III, or IV hemorrhoids. As this patients grade III internal hemorrhoids have not been responsive to conservative medical management or rubber band ligation, the Doppler guided transanal hemorrhoidal dearterialization provided on 11/20/17 was 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a nine-year-old female with no significant past medical history with early puberty and short stature. The patientas parent has requested authorization and coverage for Norditropin Flexpro 10 mg/1.5. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that in clinical practice, growth hormone therapy is considered if the predicted adult height is below the normal range. This corresponds to an adult height less than 63 inches (160 cm) for males and less than 59 inches (150 cm) for females. This is also one of the recommendations given by the U.S. Food and Drug Administration (FDA) when deciding to treat idiopathic short stature. Grimberg and colleagues recommended growth hormone therapy to normalize adult height and avoid extreme shortness in children and adolescents with growth hormone deficiency for potential benefits associated with quality of life, physical health and psychosocial wellbeing. In this case, the patient has growth hormone deficiency diagnosed after growth hormone stimulation testing. She is growing with a borderline low growth velocity of around 5 cm per year. The patientas predicted adult height is more than two standard deviations below the mid-parental height of 65.25 inches. As the predicted adult height is below the normal standard deviation range for a female in the United States, growth hormone therapy is indicated. Therefore, Norditropin Flexpro 10 mg/1.5 is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested authorization and coverage for the injectable medication Euflexxa. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees knee pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Campbell and colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. This patient presents with chronic bilateral knee pain with limited function. Clinical examination findings are consistent with bilateral knee osteoarthritis in the medial and patellofemoral compartments. She has failed to adequately respond to conservative treatment, including activity modification, nonsteroidal anti-inflammatory drugs, ice, and physical therapy. She has undergone prior Euflexxa injections, with reported pain relief and functional restoration. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Thus, the injectable medication Euflexxa is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 53-year-old female enrollee has requested reimbursement for PathFinder TG testing (84999) performed on 7/30/14.  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 differential diagnosis of pancreatic cysts includes pseudocysts, simple cysts, and cystic neoplasms.  The latter category represents cancer and requires aggressive surgical resection.  Discriminating between benign and neoplastic lesions is complicated, and current technology is limited.  Esophagogastroduodenoscopy and esophageal ultrasound are important for surveillance, but clinical observation is not definitive.  Pathology is required.  An endosonogram combined with tumor marker analysis on sampled cystic fluid can add to the sensitivity of diagnosing neoplastic disease, but it does not to the degree necessary to determine which patients require surgery. There is sufficient support for the services at issue in this clinical setting.  The current standard approach of fluid cytology is inadequate to determine the management in every patient.  In this patients case, PathFinder TG testing performed on 7/30/14 was likely to have been of greater benefit than other options for 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: Overturned

Summary Reviewer 1


A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found the request services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although, the LINX reflux management system is U.S. Food and Drug (FDA) approved it has not been demonstrated to be superior to optimal medical therapy or a standard reflux operation in controlled trials. The evidence to date has been derived from open label studies which have used patients as their own controls. In addition, dysphagia is a common adverse side effect of the procedure and can lead to long term dissatisfaction from the patient's perspective. Therefore, the patients request for the LINX device is not supported 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 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: Upheld

Summary Reviewer 1

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has chronic left sacroiliac dysfunction and pain that interferes with activities of daily living. The selected procedure of minimally invasive sacroiliac fusion using the triangular titanium implant is a relatively popular procedure, with 88 percent fusion rate and documented excellent results at five-year follow-up. Minimally invasive sacroiliac joint fusion has become an increasingly popular and accepted surgical option for chronic sacroiliac joint dysfunction, a common cause of unremitting chronic low back/buttock pain. Minimally invasive sacroiliac joint surgery has been proven to be a safe and effective procedure, with a high fusion rate, a good safety profile and significant improvements in pain severity and disability reported through 12 months post-procedure. A five-year follow-up showed continued excellent clinical responses in patients with sacroiliac joint pain treated with sacroiliac joint fusion using triangular titanium implants along with a high rate of joint fusion. Therefore, the requested minimally invasive sacroiliac joint fusion is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 51-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/13/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. The addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, the services in dispute prevented additional magnification views. For the reasons provided, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 30-year-old female enrollee has requested authorization and coverage for cervical total disc replacement surgery and one day inpatient services. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees neck pain.   The physician reviewer found that recent literature suggests that total disc replacement may provide well selected patients with superior health outcomes as compared to anterior cervical discectomy and fusion for one- and two-level degenerative disc disease. Bae and colleagues compared outcomes in a prospective randomized, U.S. Food and Drug Administration (FDA) investigational device exemption clinical trial. The authors reported that at four-year follow-up, each group demonstrated improvement in clinical outcome measures and a comparable safety profile. Davis and colleagues reviewed total disc replacement as surgical treatment of degenerative disc disease at one or two contiguous levels of the cervical spine and found similar outcomes when compared with anterior cervical discectomy with fusion (ACDF). Given this patients clinical findings and complaints, she is likely to obtain greater benefit from the requested cervical total disc replacement surgery and one day inpatient services than treatment with standard alternatives.  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.