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

Summary Reviewer 2

A 61-year-old female enrollee has requested authorization and coverage for 64568 and 0466T. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that multiple studies indicate that hypoglossal nerve stimulation is a safe and effective treatment option for moderate-severe obstructive sleep apnea patients who have failed medical therapy. The STAR trial showed that upper airway stimulation provides significant improvement in sleep-related quality of life outcome measures. Safety and stable outcome results for the hypoglossal nerve stimulation/Inspire upper airway stimulation system have been demonstrated over 48 months in the peer-reviewed literature. In sum, 64568 and 0466T are likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 61-year-old man with low back pain and radiating symptoms.  The patient has requested authorization and coverage for spinal surgery. 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 the submitted documentation supports the medical necessity of the requested services. In this case, the patient has mechanical low back pain with radiating symptoms to the thighs. Although his examination was normal, imaging showed significant spondylolisthesis. The medical literature indicates that patients with mechanical back pain associated with spondylolisthesis have superior outcomes when treated with lumbar fusion. Therefore, the requested spinal surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 37-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is investigational for treatment of the enrollees persistent asthma. The physician reviewer found that Bronchial thermoplasty is a procedure that uses a bronchoscope probe to provide thermal energy to the smooth muscle of the airway. The tissue is heated to 65 degrees Centigrade. There are three bronchoscopic procedures. The first procedure treats the right lower lobe, the second treats the left lower lobe, and the third bronchoscopic procedure is for both upper lobes. The procedures are scheduled three weeks apart. In the medical literature, the therapeutic effect of sham placebo bronchial thermoplasty was similar to bronchial thermoplasty. Castro and colleagues reported that providing thermal energy to the airway had no beneficial effect in their study of 288 patients. This patients provider states the patient has a progressive decrease in the quality of life but there is a lack of documentation that the use bronchial thermoplasty would improve the long-term functional outcome of the patients condition. For these reasons, the requested bronchoscopic thermoplasty is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 57-year-old male requested authorization and coverage for implantation of device (the Coflex device) between the bones of the spine. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees chronic lower back pain. The physician reviewer found that the current evidence based medical peer reviewed literature and long term studies support the use of Coflex interlaminar stabilization with decompression as a safe and efficacious alternative to decompression and/or lumbar fusion for the treatment of lumbar spinal stenosis. However, this patient presents with progressively worsening and debilitating low back pain. He has symptoms of neurogenic claudication with associated significant functional limitations. The signs and symptoms reported are consistent with imaging evidence of moderate to severe spinal stenosis at L4/5 with grade 1 anterolisthesis at L4/5. The U.S. Food and Drug Administration contraindications for Coflex include severe facet hypertrophy that requires extensive bone removal which would create instability. Given the presence of severe facet disease, proceeding with the Coflex device is not supported in this patients case. Therefore, implantation of the Coflex device between the bones of the spine is not likely to be more beneficial than other standard methods for the treatment of this patient. 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: Experimental
Decision: Upheld

Summary Reviewer 2


A 38-year-old male enrollee has requested authorization and coverage for neck surgery.  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested cervical disc replacement at C5-6 with Mobi-C total disc replacement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The proposed surgery, especially for single-level cervical is likely to be more beneficial than other treatment options. Moreover, the study by Jackson and colleagues found that treatment with cervical total disc replacement results in a significantly lower rate of subsequent surgical intervention than treatment with anterior cervical discectomy and fusion for both 1 and 2 levels of treatment. For the reasons provided, the requested neck surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 52-year-old male enrollee has requested reimbursement for optical endomicroscopy performed on 5/30/18. 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 the superior effectiveness of the services at issue has not been established. The American Society for Gastrointestinal Endoscopy (ASGE) noted that confocal laser endomicroscopy (CLE) is an emerging technology that has the potential to significantly reduce the number of biopsies in Barretts esophagus and inflammatory bowel disease and reduce the need for removal of non-neoplastic colorectal polyps compared with while light endoscopyLimitations of CLE include the high cost of the equipment and probes, the lack of proven efficacy compared with other widely available advanced imaging techniques, and the need for either intravenous or topical fluorescent contrast agents. Before the technology can be widely accepted, many further studies are needed to determine its clinical efficacy and evaluate its cost-effectiveness and its utilization in both academic and community settings. Intravenous fluorescein used to highlight the vasculature, lamina propria, and intracellular spaces of this tissue being examined does not stain cell nuclei. Nuclear staining can be achieved using topical contrast agents such as acriflavine and cresyl violet, but there is concern over mutagenic potential with the topical agents. In this case, the services at issue were not likely to have been of greater benefit than post-treatment histology and/or follow-up endoscopy to assess for residual dysplastic Barretts tissue. Thus, optical endomicroscopy performed on 5/30/18 was not likely to have been more efficacious than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 49-year-old female with a history of ex pleomorphic adenoma of her right lacrimal gland. The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that per the current peer-reviewed medical literature, there are insufficient high-quality clinical outcomes reported to allow one to make definitive conclusions regarding the relative safety/efficacy of proton beam radiotherapy for management of the patientas head and neck cancer, as compared to standard of care photon-based radiation therapy. In this patientas setting, proton radiation therapy has the ability to reduce the volume of low dose radiation exposure to surrounding normal critical tissues, but it cannot reduce the high dose exposure. Since it is the volume of high dose normal tissue exposure that has traditionally been correlated with radiation-induced morbidity, it remains unclear as to whether the use of proton beam radiation therapy would offer clinically meaningful improvements in outcomes in this patientas case. The treating provider has not supplied a detailed slice-by-slice proton/photon plan comparison in color format to justify the need for proton beam radiation therapy. Typically, a photon-based plan would be associated with a high level of safety/efficacy, and this is supported by high-quality outcomes published in the peer-reviewed medical literature. There are not any extenuating circumstances present in this case that would necessitate the use of proton beam radiation therapy, such as prior receipt of radiation to the same site or genetic/comorbid condition, which increases normal tissue radiosensitivity.  The records do not demonstrate that this patient could not be treated safely and effectively with photon-based radiation therapy in the form of intensity modulated radiation therapy. Therefore, proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 68-year-old female enrollee has requested authorization and coverage for Glumetza. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees type 2 diabetes. The physician reviewer found the request for Glumetza is medically necessary for treatment of the patients medical condition. According to the American Diabetes Association guidelines, metformin is first line of therapy in patients with diabetes type 2. It also should be a component of combination therapy as step-up therapy is prescribed. The most common side effect to intermediate release metformin is gastrointestinal (GI) intolerance, therefore several preparations are available (Jabbour and Ziring). In this case, the patient had adverse reaction to generic metformin and has been able to tolerate the brand Glumetza. Glumetza utilizes a modified delivery system, polymer-based, oral drug delivery systems, which allow delivery of metformin hydrochloride to the upper GI tract. There is no generic form of Glumetza. In the aqueous GI environment, the dosage form swells remarkably thereby increasing in size and geometry from where drug is released slowly by a process of diffusion through the gel matrix that is independent of pH. Even though the active component is the same, the delivery systems differ, and therefore it is likely that the patient had an adverse reaction to the generic delivery systems. It is therefore medically necessary that this patient continue taking Glumetza as part of her diabetes management. 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: Upheld

Summary Reviewer 3

A 38-year-old male enrollee has requested authorization and coverage for neck surgery.  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that there is insufficient data in the medical literature to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential problems that may occur with longer follow-up have not been fully documented. Additionally, total disc arthroplasty has been associated with substantial morbidity. In this clinical setting, the gold standard procedure would be a single level anterior cervical discectomy and fusion. In sum, the requested services are 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 services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a four-year-old male enrollee has requested reimbursement for FirstStepDx Plus dated 5/12/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found that chromosomal microarray (CMA) and Fragile X testing are recommended by the American College of Medical Genetics (ACMG) as a first-tier tests for patients with ASD. The yield of CMA in patients with ASD is estimated to be around 10%. CMA has become the standard of care for diagnosis in patients with ASD. Increasing numbers of patients with ASD have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ASD due to that underlying cause. Additionally, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. Fragile X is one of the most common causes of ASD in males. As many as 6% of males with ASD have been found to have Fragile X. Identification of Fragile X will have increasing importance as growing numbers of clinical trials for therapeutic agents begin for Fragile X. All told, the FirstStepDx Plus performed on 5/12/16 was 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 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 2


The parent of a five-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15. 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 FirstStep DX Plus testing performed on 10/15/15 was likely to be more effective for this patient with autism than other available treatment options. The study by Henderson and colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings reported per laboratory over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that, These results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Based on the support in the medical literature, the comparative genomic hybridization (CGH) FirstStep DX Plus testing performed on 10/15/15 was 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 75-year-old male initially diagnosed with a prostate cancer in 2022. The patient 
has requested authorization of coverage for SBRT. The Health Insurer has denied coverage stating 
that SBRT is not medically necessary. The physician reviewer found that the management of 
metastatic prostate cancer has been focused on systemic therapies such as hormonal therapy, 
chemotherapy,  or  immunotherapy.  However,  the  advent  of  newer  molecular  sequencing 
techniques and targeted systemic treatments has allowed providers create tailored systemic 
therapies to address unique tumors in individual metastatic prostate cancer patients. Patients 
who respond well to these targeted systemic therapies demonstrate good disease response, yet 
it is still common for certain localized metastatic tumor deposits to continue to grow despite 
good  overall  disease  control  in  the  rest  of  the  body.  This  disease  state  is  referred  to  as 
oligometastatic disease, and this is considered a strong indicator for SBRT. As noted in the 
medical literature, SBRT uses special beam technique that allows for delivery of high doses of 
radiation while sparing adjacent normal tissue. There is strong evidence showing improved 
overall survival and progression-free survival with the addition of SBRT to immunotherapy in an 
oligometastatic setting (Pla, et al.; Lin, et al.). In addition, SBRT technique allows for higher doses 
to be delivered with greater precision and these higher ablative doses have demonstrated high 
local control when treating localized lesions (Navarria, et al.; Ning, et al.). Moreover, standard 
radiation therapy has shown some detriment in this setting compared to SBRT, due mainly to a 
less effective immune response (Gong, et al.; Khalife, et al.). This patient has a number of 
treatment targets located in the thorax and pelvis, so decreased radiation dose is critical in this 
setting. In conclusion, the safest way to deliver the necessary radiation dose to this patient is 
with SBRT technique. Therefore, the requested per fraction to one or more lesions, including 
image guidance, entire course not to exceed five fractions, is medically necessary for treatment 
of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 31-year-old male enrollee has requested reimbursement for mental health intensive outpatient treatment provided from 8/02/18 through 9/04/18. 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 in 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 1 due to a lack of current suicidal ideation or past suicide attempts. With regards to functional status, the records support a score of 1 due to apparent transient impairment in functioning. His activities of daily living were intact. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to the existence of medical problems which were not immediately threatening and had no impact on the course of his present illness. With regards to level of stress of the recovery environment, the records support a score of 1. His living environment posed no significant threats or risks. In terms of level of support of the recovery environment, the records support a score of 2. Some elements of his support system were willing and able to participate in treatment, if requested, as referenced by including his family in treatment. With regards to treatment and recovery history, the records support a score of 2. The patients substance sobriety has been managed for moderate periods of time. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment with his current provider. Therefore, the patient has a composite score of 11. This score correlates with clinic-based services without frequent contact. Thus, the patient could have safely been treated in a less restrictive setting. Therefore, mental health intensive outpatient treatment provided from 8/02/18 through 9/04/18 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 44-year-old female enrollee has requested reimbursement for monitored anesthesia care provided on 7/17/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care provided on 7/17/15 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.