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

Summary Reviewer 3

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 there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment (Sheu, et al; Ganz). For these reasons, 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: Overturned

Summary Reviewer 2


A 35-year-old female enrollee has requested reimbursement for NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for treatment of the enrollees pregnancy. The physician reviewer found that Cell-free DNA screening (cfDNA) has emerged as an important advance in screening pregnant women for common aneuploidies, specifically those seen more commonly with advanced maternal at age 35 or older at the time of delivery. While cfDNA screening is not recommended for all pregnant women in the place of traditional first and second trimester screening, most genetic societies support cfDNA testing for primary screening for higher-risk pregnant populations, including patients who of advanced maternal age at delivery. In this case, the patient had an estimated age of 35 at the time of delivery and meets the criteria for this test. In addition, national guidelines support that pregnant women should be screened for carrier status for cystic fibrosis and spinal muscular atrophy with the extended carrier screening test. In this case, the testing at issue was clinically indicated as part of the patients standard prenatal care. Accordingly, the NxGen MDx Universal panel and Harmony Prenatal test provided on 11/12/15 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a nine-year-old female who has been diagnosed with phonological disorder. The patientas parent has requested reimbursement for speech therapy provided from 1/04/19 through 12/25/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. Law and colleagues examined the effectiveness of speech and language interventions for children with primary speech and language delay/disorder. The authors reviewed twenty-five studies in their meta-analysis, concluding that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The American Speech-Language-Hearing Association guidelines note, aPhonological/language-based approaches target a group of sounds with similar error patterns, although the actual treatment of exemplars of the error pattern may target individual sounds. Phonological approaches are often selected in an effort to help the child internalize phonological rules and generalize these rules to other sounds within the pattern (e.g., final consonant deletion, cluster reduction).a Wren and colleagues noted, aChildren with persistent speech disorder (PSD) are at higher risk of difficulties with literacy, with some evidence suggesting an association with poorer educational attainment.a There is sufficient support for the services at issue in this clinical setting. Therefore, speech therapy provided from 1/04/19 through 12/25/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 57-year-old male who has a history of infrequent brief episodes of tachycardia usually controlled by Valsalva maneuver. The record indicated that episodes were occurring more frequently with the last one occurring approximately one month prior to his cardiology evaluation. An electrophysiology (EP) study failed to reproduce his clinical arrhythmia and the provider recommended and placed an implantable loop recorder. The patient has requested reimbursement for implantable event recorder inserted on 9/20/17. The Health Insurer has denied this request on the basis that the procedure at issue was investigational for treating this patients medical condition. The patient did not have a diagnosis to reproduce the clinical arrhythmias despite EP testing. His symptoms were infrequent and brief but of increased frequency. The guidelines support the use of the implantable loop recorder in this clinical setting.  Given the unusual situation with a difficult diagnosis of the arrhythmia in this patients case, the use of the implantable loop recorder was an effective treatment option. In this case, this is more likely than standard therapy to be beneficial in this individual's treatment. In sum, the implantable event recorder inserted on 9/20/17 was likely to have been more beneficial than the standard therapy for the treatment of this patients medical condition. Based upon the information set forth above, the procedure at issue was 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: Upheld

Summary Reviewer 

A 49-year-old male enrollee has requested reimbursement for residential mental health treatment provided from 8/29/18 through 8/31/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 2 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level at home with some issues with daily activities, but no significant functional problems. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and no active substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family members. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment and family that is supportive of his treatment. With regards to treatment and recovery history, the records support a score of 3 due to moderate perceived treatment response in the past with residential treatments. Of note, the patients symptom presentation does not indicate a lack of response from recent treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment and apparent insight into the need for treatment. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient treatment. Thus, residential mental health treatment provided from 8/29/18 through 8/31/18 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 17-year-old female enrollee has requested reimbursement for inpatient residential mental health treatment provided from 1/16/15 through 6/01/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the patient was diagnosed with major depressive disorder, recurrent, moderate with anxious distress, bulimia nervosa, panic disorder, generalized anxiety disorder, and borderline personality disorder.  She has a history of multiple hospitalizations for suicidal ideation/attempts in the year prior to admission, which impaired her functioning across multiple settings.  Per the submitted documentation, she had one documented intensive outpatient program experience from 7/18/14 through 7/20/14, in between two inpatient admissions.  The patient and her family were committed to treatment, and she stated that she wanted to work on her suicidality, eating disorder, and self-harm behaviors.  At the time of admission on 1/16/15, a lower level of care was not appropriate to meet her needs, as she required more intensive monitoring.  In this patients case, inpatient residential mental health treatment was medically indicated from 1/16/15 through 1/28/15.  By 1/28/15, although still reporting depression, the patient rated her mood as 6/10.  The patients baseline behavior, prior to admission, is the expression of suicidal ideation and self-harm urges.  Much of her self-harm behaviors were scratching herself with her fingernails.  These behaviors continued throughout her stay and can be considered chronic in nature, which would not require treatment at residential level of care.  All told, inpatient residential mental health treatment provided from 1/16/15 through 1/28/15 was medically indicated for the treatment of this patient, but not thereafter.  Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 39-year-old female enrollee has requested authorization and coverage for Simponi injections 100 mg/ml.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriatic arthropathy. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records document a history of psoriasis and psoriatic arthritis.  In this case, the recent notes indicate that the patient was not currently taking methotrexate as prescribed since at least November 2016.  Per the records, she had responded to methotrexate and Otezla in the past and had stopped Simponi at that time. There is currently a lack of guidelines or large randomized controlled trials which recommend the use of a tumor necrosis factor inhibitor, like Simponi, in combination with Otezla.  The records fail to demonstrate that she has failed treatment with a tumor necrosis factor inhibitor in combination therapy with methotrexate, or Otezla with methotrexate. As such, the request for Simponi in combination with Otezla is not medically necessary.  Thus, the requested Simponi injections 100 mg/ml are not medically indicated for the treatment of this patient.  Thus, 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 3

The patient is a 46-year-old female with a history of neck pain and numbness in both hands and feet, greater on the left. On 3/22/17, the patient presented for follow up status post facet blocks from C5-7 with temporary relief and recurrence of symptoms. By report, x-rays showed increased collapse of C5-6 level and C6-7 intervertebral collapse. Magnetic resonance imaging (MRI) demonstrated significant foraminal stenosis at both levels. The patient has failed conservative management and the provider recommended two level cervical disc replacement. The patient has requested reimbursement for cervical artificial discectomy performed on 4/13/17. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational. The medical records show that the patient has evidence of three levels of cervical degeneration from the C3 to C7 levels. However, there is a lack of well conducted randomized controlled clinical trials demonstrating superior health outcomes with use of cervical artificial discectomy compared to standard available interventions. All told, the cervical artificial discectomy performed on 4/13/17 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, the surgery 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: Overturned

Summary Reviewer 3 
A 40-year-old female enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve. The Health Insurer has denied this request indicating that 
the requested services are considered investigational for treatment of the insureds spondylosis 
without myelopathy or radiculopathy, lumbar region. The physician reviewer found that this 
patient has a longstanding history of low back pain that is purported to be vertebrogenic. The 
records indicate the pain occurs in the patients low back with prolonged sitting, standing, 
bending. and lifting that is improved with rest and walking. The records suggest that this patients 
pain is primarily axial in nature. The patient experienced six months of pain relief with lumbar 
epidural steroid injections in the past. Recent epidural steroid injections provided 30% relief. The 
patients pain could be vertebrogenic or facetogenic based on the movements that provoke her 
pain in the clinic notes. Radiofrequency ablation of medial branch nerves is a standard therapy 
often used to treat facet mediated pain. Based on the available documentation, it has not been 
determined  whether  the  patient  has  facet  mediated  pain  and  if  she  might  benefit  from 
radiofrequency ablation. Also, there is a lack of comparative studies of basivertebral nerve versus 
radiofrequency ablation of facets for the treatment of patients with chronic low back pain. It 
cannot be determined that basivertebral nerve would be superior to radiofrequency ablation of 
medial branch nerves in this case. In sum, the requested thermal destruction of intraosseous 
basivertebral nerve is not likely to be more beneficial for treatment of the patients medical 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 64-year-old female with a history of severe obstructive sleep apnea as diagnosed from a home sleep study. She was treated with continuous positive airway pressure (CPAP), but was unable to tolerate this therapy. The patient is status post septoplasty and bilateral inferior turbinate reduction. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  The submitted documentation fails to demonstrate the superior efficacy of the requested device. A home sleep study performed on 10/12/17 showed an apnea-hypopnea index of 43.0.  The records do not document what measures were done to help the patient tolerate CPAP. Positive airway pressure therapy is the gold standard in this clinical setting. Thus, implanted nerve stimulator is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested device 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: Medical Necessity
Decision: Upheld

Summary  
The patient is a 61-year-old male with a history of bilateral knee pain and a diagnosis of primary 
osteoarthritis of both knees. Upon his initial consultation on in 2021, the provider noted that both 
of the patients knees have end-stage degenerative joint disease. The Health Insurer has denied the 
requested services as not medically necessary. The physician reviewer found that the records 
indicate that this patient is being treated for unilateral primary osteoarthritis of the left knee. In 
April 2022, the patient presented status post right knee replacement with satisfactory results. The 
patient has since expressed interest in proceeding with left total knee replacement. The provider 
noted that physical examination of the left knee revealed a mild varus deformity, significant pain 
along the medial aspect to palpation, and crepitus with range of motion. The provider has 
recommended treatment with left total knee arthroplasty. However, the available documentation 
does not include evidence a follow-up examination since 4/6/22. In the absence of an updated 
examination including both subjective and objective findings, the available records do not support 
the medical necessity for the requested left total knee arthroplasty. Riddle and colleagues noted 
that the risk-to-benefit for total knee arthroplasty favors patients who have intense or severe 
symptoms of knee osteoarthritis (OA), are at least 55 years old, have limited mobility, and have a 
body mass index (BMI) less than 40 kg/m2. The authors concluded that, Outcomes are much 
less favorable for patients who have slight or moderate symptoms and functional loss, making the 
procedure not appropriate. On the 4/6/22 examination, this patients left knee symptoms were not 
described as severe and the patients BMI was reported at 34.86 kg/m2. In the absence of current 
physical examination findings, the severity of the patients condition and/or BMI may have 
significantly changed (Calek and Behrend). Additionally, detailed documentation is not evident 
regarding a trial and failure of recent, reasonable, and comprehensive less invasive conservative 
care measures for the patients left knee (Van Zaanen, et al.). For these reasons, the requested 
arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella 
resurfacing (total knee arthroplasty) is not medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 28-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation and autologous cultured chondrocytes implant for left knee. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees left knee pain. The physician reviewer found that treatment of osteochondral defects with autologous chondrocyte implantation has been proposed for treatment of this patients cartilage defects in the knee. However, the current peer-reviewed medical literature provides limited support of this procedure in this clinical setting. The study by Andriolo and colleagues demonstrated additional studies are required. Similarly, Mistry and colleagues concluded that research is needed to fully assess the long-term results of autologous chondrocyte implantation. Given the absence of data supporting improved patient health outcomes with the requested procedure, autologous chondrocyte implantation and autologous cultured chondrocytes implant for left knee are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 49-year-old male with a history of lumbar stenosis without neurogenic claudication, lumbar degenerative disc, right sciatica and lumbosacral herniated disc. The patient has requested authorization and coverage for laminotomy with decompression of nerve, including partial facetectomy, foraminotomy and/or excision of herniated disc. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Held and colleagues concluded that there was strong evidence that surgical treatment is superior to non-operative treatment for elderly patients with degenerative lumbar spinal stenosis. Weinstein and colleagues found that patients with symptomatic spinal stenosis treated surgically maintain substantially greater improvement in pain and function through four years compared to those treated nonoperatively. Jarrett and colleagues reported that their systematic review of the recent literature demonstrates that decompressive surgery is more effective than land-based exercise in the management of lumbar spinal stenosis. However, given the conditions slowly progressive nature and the potential for known surgical complications, they recommended that a trial of conservative management with land-based exercise be considered prior to consideration of surgical intervention. Kovacs and colleagues concluded that decompressive surgery, with or without fusion, was more effective for patients with symptomatic lumbar spinal stenosis than continued conservative treatment when the latter had failed for three to six months. In this case, the records document continued complaints of worsening low back and right lower extremity pain. He has had severe numbness and tingling. There is a grossly positive straight leg raise producing low back pain. MRI documents right paracentral/foraminal disc herniation at L5-S1 measuring 18 x 4 mm, resulting in severe right lateral recess stenosis with compression of the right S1 nerve root. Provided documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities has been documented. The current medical evidence supports the requested services in this clinical setting. Therefore, laminotomy with decompression of nerve, including partial facetectomy, foraminotomy and/or excision of herniated disc is medically necessary for the treatment of this patient.