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

Summary Reviewer 

The patient is a 55-year-old male who was hospitalized from 6/08/20 through 6/11/20. The patient has requested reimbursement for air ambulance services provided on 6/11/20. The physician reviewer found that in order for air medical transport to be medically necessary, all medical necessity criteria must be met. These criteria include: the individualas condition must be such that any form of transportation other than ambulance would be medically contraindicated; the individualas condition is such that time needed to transport by ground poses a threat to the patientas survival; the individual is transported to the nearest hospital with appropriate facilities for treatment; and there is a medical condition that is life-threatening. When transporting from one facility to another, the above criteria must be met, and the first hospital does not have the required services and facilities to treat the patient. The patientas provider noted that El Centro Regional Medical Center does not have an intensivist available to help manage an intubated patient and that was the reason for transfer to Cedar Sinai. It appears from this provideras note that Cedar Sinai was the closest available facility with an intensive care unit (ICU) available capable of accepting the patient. Therefore, air ambulance services provided on 6/11/20 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/15/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found in recent years, several studies support the use of breast tomosynthesis as a more accurate study than routine screening mammography. Medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  As noted in a paper by Helvie and colleagues, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. In this particular patient, as discussed by Kopans and colleagues, tomosynthesis is valuable in the evaluation and optimizing visualization of suspicious breast calcifications. Thus, the submitted documentation supports the service at issue in this clinical setting as tomosynthesis 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 66-year-old male enrollee has requested authorization and coverage for Repatha Sureclick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient presents with some coronary risk, including hyperlipidemia, but no documented clinical cardiovascular disease.  Coronary calcification does not equal coronary stenosis. Repatha (evolocumab) is a proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic cardiovascular disease who require additional lowering of LDL cholesterol. This patient does not fit either of those criteria. There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia. These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged younger than 55 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.   There is a lack of documentation to confirm the presence of obstructive coronary or vascular disease.  Repatha has not been adequately studied in the setting of primary prevention in patients with increased coronary risk but no evidence of clinical obstructive cardiovascular disease, such as this patient. Current guidelines that are endorsed by several national organizations also do not recommend the use of PCSK9 inhibitors in this primary prevention setting. Therefore, Repatha SureClick is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer has denied this request indicating that the requested equipment is considered investigational for treatment of the enrollee who had sustained an injury to his upper right arm. The physician reviewer found that the patient is a 41-year-old male who sustained a right brachial plexus injury in December 2014. He underwent nerve and tendon grafting in July 2015 and February 2016 with less than expected recovery. He has a three out of five strength to his right hand and two out of five strength in his right shoulder and elbow. A Wilmer carrying orthosis has been utilized for static splinting but affords no functional benefit. Prior to the accident this patient was independent with all activities but he currently requires assistance with activities of daily living (ADL). The patient requested authorization and coverage for myoelectric, upper extremity orthosis. The Health Insurer denied the requested equipment as investigational for treatment of the patients medical condition.
The medical literature supports the superior efficacy of the requested equipment, in this clinical setting. The custom myoelectric elbow wrist orthosis will allow greater benefit than the standard static orthosis that this patient is currently utilizing. There are multiple studies proving the benefit of myoelectric orthoses for a plegic upper extremity. In a study by Ogce and Ozyalcin, they document the benefits of a myoelectrically controlled shoulder-elbow orthosis for brachial plexus injury. In this patients case, he has exhausted several conservative options including splinting, orthoses, therapy, and surgical nerve and tendon transfer. The myoelectric orthosis has been shown to improve function in a plegic extremity. The equipment would allow elbow flexion and extension with an articulated wrist.  Moreover, this equipment would facilitate independence with ADL, in this case. Currently, the patient requires assistance with his ADL. As such, the requested myoelectric, upper extremity orthosis, is likely to be more effective than the standard options available for treatment of this patient. Based upon the information set forth above, the requested equipment 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: Upheld

Summary  
The patient is a 53-year-old female. In a letter dated 12/13/22, the provider reported that the patient 
was diagnosed in April 2022 with primary melanoma of the cervix with an erythroblastic oncogene 
B (ERBB)2 V777L mutation.). The patient has requested authorization and coverage for Tukysa 
(tucatinib) 150 mg #120/30 days. The Health Insurer has denied this request and reported that 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 does not support the medical necessity of the requested medication. The use of 
Tukysa (generic name tucatinib) is not approved by the U.S. Food and Drug Administration (FDA) 
for the treatment of melanoma, nor is it supported by the National Comprehensive Cancer Network 
(NCCN) guidelines for the treatment of cutaneous melanoma or major drug compendia. While 
Gottesdiener and colleagues note that there is some limited data to support the use of other HER2 
treatment such as trastuzumab ematansine, given that current medical literature does not support 
the use of Tukysa for ERBB2 related melanoma, the requested medication is not medically 
indicated. Therefore, Tukysa (tucatinib) 150 mg #120/30 days is not medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient has already undergone great saphenous vein removal.  The reflux from the incompetent saphenofemoral junctions is now going down the accessory saphenous veins.  These veins are very large, and have free reflux.  They are essentially acting as refluxing greater saphenous veins. In the situation where these veins can be ablated, this treatment is standard of care.  All told, the requested ablation of varicose veins, right and left accessory ablation is likely to be of greater benefit than other treatment options.  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 1

A 37-year-old female enrollee has requested reimbursement for gene testing provided on 9/16/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines have not been determined if molecular markers are useful in treatment determination and prognosis other than those established markers for breast cancer such as ER, PR and HER2. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Given the lack of definitive support in the peer-reviewed literature, the gene testing provided on 9/16/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 48-year-old female has requested reimbursement for Anser IFX testing performed on 9/04/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns colitis. The physician reviewer found the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Based on the medical literature, Anser IFX testing performed on 9/04/15 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement for office visits, acupuncture and physical therapy provided from 11/05/18 through 2/01/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records do not indicate that the patient had a condition other than a back sprain/strain injury with persistent mechanical low back pain, with possible radiculitis. These are conditions that heal spontaneously, and symptoms generally improve over time with relative rest and palliative measures, as needed. Palliative measures can form a mainstay of treatment for those with significant persistent symptoms, but no marginal objective benefit in course or outcomes would be expected with formal interventions (including acupuncture, infrared therapy and manual therapy) over independently applied measures, such as topical heat, foam rolling, over the counter analgesics, education and reassurance. Secondary preventive measures, such as education with regards to exercise and lifting technique, can be employed by understanding the specific details regarding how the patient may have sustained the original back injury and, thereby, implementing appropriate measures to mitigate risk of re-injury. In this case, there was insufficient documented history with regards to the specifics of his exercise program. Only exercise time exposure characteristics for his type of exercise (weightlifting) are described. Otherwise, generalized measures, such as strengthening the core and staying active with exercise, could have been pursued. The medical evidence does not support the services at issue in this clinical setting. Therefore, office visits, acupuncture and physical therapy provided from 11/05/18 through 2/01/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 57-year-old female with a history of left knee pain. The patient has requested authorization and coverage for left knee arthroscopy with partial meniscectomy and chondroplasty. 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 recent studies have conclusively shown that outcomes after an arthroscopic partial meniscectomy are no better than the outcomes after a sham/placebo surgery. Meniscal repair is now being touted as a viable and effective alternative. However, meniscal repairs depend upon the location of tear in the peripheral red zone of the meniscus. Meniscal repairs have been proven to be a much more efficient alternative to partial meniscectomy. It is now increasingly recommended to attempt meniscal repair in all repairable tears, especially in young and physically active patients. Partial meniscal implants have also shown excellent outcomes in long-term studies, but its efficacy in acute settings still requires further research. Research in regenerative medicine also looks promising for the meniscal tissue. In this case, the patient has documented degenerative changes in the medial articular surface of the patella and trochlea. The two reported tears are small and involve the inferior aspect of the medial meniscus in the posterior horn and the body. These are likely degenerative in nature. There are no mechanical symptoms documented, and the tears are stable. Focal cartilage lesions seen on MRI, such as fissuring in this case, warrant a trial of conservative treatment, such as physical therapy, home exercise program, nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections or viscosupplementation, which has not been documented. Furthermore, the location of pain has not been documented to be anterior, and so it is not known if patellar chondromalacia is the pain generator. Chondroplasty has short-term efficacy for pain relief and may be done as a part of the arthroscopic procedure of partial meniscectomy, which is not indicated for the aforementioned reasons. Therefore, the requested left knee arthroscopy with partial meniscectomy and chondroplasty is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 58-year-old female enrollee has requested authorization and coverage for a left total knee arthroplasty. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the records document chronic left knee pain due to severe osteoarthritis. The arthritis is tricompartmental, with the medial compartment being bone-on-bone. She has severe pain with ambulation and also complains of nocturnal pain interfering with sleep. The provider has documented trial/failure of conservative treatment for several years. On examination, there is a varus deformity. The provider has opined that the patient is a good candidate for outpatient total knee arthroplasty. In reviewing the medical records, the patient does meet the criteria for a successful outpatient total knee arthroplasty. Her age, activity status, degree of pain, nocturnal symptoms, failure of conservative treatment, and radiographic criteria of severe osteoarthritis of the medial compartment and lesser degree of osteoarthritis in the remaining compartments, all meet the guidelines for a successful total knee arthroplasty. The providers request for an outpatient total knee arthroplasty is supported by the medical literature. Therefore, the requested left total knee arthroplasty is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested authorization and coverage for Euflexxa injections. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees osteoarthritis of the bilateral knees. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Axe and colleagues report that intra-articular (IA) viscosupplementation using hyaluronic acid (HA) demonstrates anti-inflammatory, anabolic, and analgesic effects. The authors state Use of IA HA has also shown to delay total knee arthroplasty. Moreover, the literature review by Cheng and colleagues state We conclude that strong evidence supports the use of intra-articular knee injection as a valuable intervention in the continuum of management of arthritis between conservative treatment and knee surgeries. In this case, the clinical documentation submitted for review indicates the patient has osteoarthritis of the bilateral knees. The patient has been treated with Euflexxa injections and reported relief from 2011 until 2014. As such, additional injections would be medically necessary in this clinical setting. Based on the medical records submitted and the peer-reviewed literature, the request for Euflexxa injections are medically necessary for the treatment of the patients medical condition. For the reasons provided, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that Cardioverter defibrillator implantation is a Class IIa recommendation in patients with cardiac sarcoid, independent of ventricular function, if there is an indication for permanent pacemaker implantation. In this patients case, given the symptomatic bradycardia due to intermittent second degree heart block, a permanent pacemaker is indicated. Therefore, an implantable cardioverter defibrillator is indicated. This is due to the increased risk for sudden cardiac death with this type of cardiomyopathy. Therefore, the requested cardioverter defibrillator is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device 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.