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

Summary Reviewer 

A 49-year-old transgender female enrollee has requested reimbursement for tracheal shave provided on 3/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has well-documented gender dysphoria. Per her medical records, she had social anxiety and depression related to being perceived as male by others. The records document clinically significant distress from having masculine features. Under these circumstances, the tracheal shave performed was medically necessary for the treatment of her gender dysphoria. World Professional Association for Transgender Health (WPATH) criteria for surgery state that other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adams apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). The current medical evidence supports the services at issue in this clinical setting. Therefore, tracheal shave provided on 3/26/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for prenatal testing performed on 1/10/14. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees suspected fetal abnormality. The physician reviewer found in this case, the prenatal cell-free DNA screening provided on 1/10/14 was likely to be more beneficial than other modalities. The patients 18-week ultrasound revealed two soft markers associated with an increased risk of aneuploidy. The American College of Obstetricians and Gynecologists Committee on Genetics recommend women regardless of maternal age be offered cell-free DNA who present with ultrasonographic findings indicating an increased risk of aneuploidy. This patient presented with ultrasound markers associated with an increased risk of aneuploidy. As such, the testing at issue was likely to be more beneficial than other modalities. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old female enrollee has requested reimbursement for computed tomography (CT) scan of the abdomen and pelvis performed on 12/11/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patients case. In the setting of acute/subacute abdominal pain with associated nausea and vomiting, the range of pathology is broad and includes gastrointestinal, biliary, pulmonary and genitourinary pathology. Imaging plays a key role in this setting to help direct management and treatment. CT of the abdomen and pelvis, preferably with oral and intravenous contrast, has been proven to improve the final diagnosis and management of patients presenting with abdominal pain. In this case, the CT of the abdomen and pelvis could have impacted patient management. Therefore, CT of the abdomen and pelvis performed on 12/11/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3
A 52-year-old male enrollee has requested authorization and coverage for implant stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees complex regional pain syndrome to his right foot. The physician reviewer found that the medical records provided for review indicate a condition of chronic back pain with degenerative disc disease and previous spine surgery.  There is documentation regarding previous conservative care and treatment response to date but also notes little improvement with spinal cord stimulator trial. However, implanted stimulator, permanent placement is not supported unless at least 50% improvement in pain with demonstrated functional gain. Babu and colleagues reported that permanent placement outcomes are maximized when at least 50% improvement in pain and functional gain is used to measure success. Provenzano and colleagues noted the effectiveness of implanted stimulator but reflects that placement is only supported for those cases with demonstrated functional improvement. The medical records provided do not indicate that this threshold has been met in this patient.  In sum, spinal cord stimulation permanent placement is not likely to be more efficacious in this patients case than the standard options available for treatment. Therefore, for the reasons stated 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 36-year-old female enrollee has requested authorization and coverage for Sunosi 75 mg tablet. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  medication  is 
investigational for the treatment of the enrollees idiopathic hypersomnia. The physician reviewer 
found that Idiopathic hypersomnia (IH) is a syndrome with no known cause. Standard treatment is 
first addressing treatable causes of sleepiness and then using wake-promoting medications and 
stimulants to combat daytime sleepiness. While there is a lack of published studies on the use of 
solriamfetol  in  IH, improvement  to  daytime  sleepiness  may  be  extrapolated  from  literature 
showing the efficacy of these agents in the treatment of conditions such as narcolepsy type 1. In 
terms of addressing the treatable causes of sleepiness, the American Academy of Sleep Medicine 
confirms the necessity of sleep-tracking by actigraphy or sleep logs prior to testing. In this case, 
the  records  did  not  include  enough  data  to  exclude  insufficient  sleep  as  a  cause  of 
hypersomnolence, and less than seven hours of sleep were confirmed before the MSLT on the 
overnight sleep study. The patient's average subjective sleep time of only seven hours during the 
week and eight to eight and half hours on the weekend may warrant a trial of sleep extension of 
eight to nine hours per night, with confirmation using sleep tracking methods, as a first step prior 
to  wake-promoting  medications.  Current  medical  literature  supports  the  use  of  medications 
including modafinil, methylphenidate, oxybate salts, pitolisant, and clarithromycin. In this case, 
the records did not document that armodafinil, which is identical to modafinil, was prescribed at 
the maximum dosage of 250 mg daily, or that oxybate salts, pitolisant, and clarithromycin were 
previously used or contraindicated. The records indicate that Adderall is prescribed as needed, but 
without an explanation on why it, or its extended-release version, cannot be used regularly at a 
higher dose if well-tolerated. In this clinical setting, there is a lack of support in current medical 
literature that Sunosi is likely to be more beneficial than standard therapies such as sleep-extension, 
increased dosage of current medications, or other medications recommended in current medical 
literature for the treatment of idiopathic hypersomnia. Therefore, Sunosi 75 mg tablet is not likely 
to be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 64-year-old female enrollee has requested reimbursement for FoundationOne test performed on 1/19/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that this patient has exhibited toxicity to a standard regimen for colon cancer. Patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study by Von Hoff and colleagues involved 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Accordingly, FoundationOne test performed on 1/19/17 was likely to have been of greater benefit than standard available methods of evaluating this patients medical condition. Therefore, for the reasons stated 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 63-year-old male who was found to have an elevated prostate-specific antigen (PSA) level. He was referred for magnetic resonance imaging (MRI) of the prostate gland, which was performed on 4/13/19. The physician reviewer found that currently, the diagnostic pathway for prostate cancer detection is often initiated by PSA level testing and digital rectal examination. This is often followed by transrectal ultrasound guided biopsy (TRUS). However, anterior tumors within the prostate are often missed by TRUS. Further, TRUS biopsy has historically underestimated the final Gleason grading, leading to inaccurate risk stratification and selection of therapeutic options. Magnetic resonance imaging has been used for noninvasive assessment of the prostate gland since the 1980s. Initially, prostate MRI was based solely on morphologic assessment using T1-weighted and T2-weighted pulse sequences, and its role was primarily for locoregional staging in patients with biopsy proven cancer. However, it provided limited capability to distinguish between pathologic tissue and clinically insignificant prostate cancer from significant cancer. Advances in technology, however, have dramatically changed MRI imaging for prostate cancer. The center that had performed this patients MRI refers to this advanced technology as three-dimensional rendering. In fact, three-dimensional rendering is an older term to describe what is widely described as multiparametric MRI. By using
these newer techniques, which are widely accepted, one is able to obtain three-dimensional volumetric images. By obtaining images from the whole area within the body, there is a higher signal-to-noise ratio, making the images sharper and more accurate in detecting lesions. This technique also allows fusing the MRI to ultrasound and to guide TRUS. The medical evidence supports the services at issue in this clinical setting. As stated by Girometti and colleagues, Multiparametric magnetic resonance imaging is the standard of care for assessing prostate cancer. Therefore, three-dimensional rendering with interpretation and reporting of magnetic resonance imaging performed on 4/13/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 48-year-old male enrollee has requested reimbursement for unlisted multianalyte assay with algorithmic analysis performed on 11/25/19. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests, such as DecisionDx-Melanoma testing are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Therefore, unlisted multianalyte assay with algorithmic analysis performed on 11/25/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health residential treatment services provided from 4/9/14 forward. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse and parent-child relational problem.  The physician reviewer found that the records submitted for review indicate that the patient had a significant substance abuse history and he had just gone away without leave from his previous placement. However, there is no indication that placement in this facility was geared to address motivational concerns or that the patient had any symptoms requiring 24-hour support and intervention. According to the American Psychiatric Association (APA) practice guidelines, patients with substance use disorders should be treated in the least restrictive setting which is likely to be safe and effective. There is a lack of evidence that this patients substance abuse presented an imminent safety risk or that he could not have been managed effectively on an ambulatory basis. Further, there is no documentation of withdrawal symptoms. Overall, the chart reviewed fails to support the medical necessity of residential substance abuse services from 4/9/14 through 10/19/14 and ongoing. Based on the foregoing discussion, I have concluded that the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for Oncotype DX colon cancer assay completed on 8/19/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that this patient had stage II colon cancer. Although Oncotype DX colon cancer assay provides prognostic data, to date, it does not provide predictive data for the benefit of chemotherapy.  Per the medical evidence, the clinical utility of gene expression assays, including the 12-gene recurrence score, is uncertain. Information is lacking regarding the extent to which assay results do or do not classify patients into distinct groups with clinical relevance.  National Comprehensive Cancer Network guidelines state that there are insufficient data to recommend the use of multigene assays, such as the Oncotype DX colon cancer, to determine adjuvant therapy.  The perforation of this patients tumor despite negative nodes would favor treatment with chemotherapy. As such, the use of Oncotype DX colon cancer assay on 8/19/15 was not likely to have been more beneficial than using standard factors in determining the need for adjuvant therapy for the evaluation of this patient.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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 2

A 29-year-old female enrollee has requested reimbursement for human papilloma virus (HPV) testing performed on 9/29/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the patient has a history of high-grade HPV testing in 2017. Her testing in 2020 showed atypical squamous cells of undetermined significance (ASCUS) cytology with HPV. On 9/29/20, the records noted that she was evaluated with a Pap smear one year prior, and her gynecologist recommended colposcopy following an abnormal Pap smear. There is no clinical documentation from her gynecology visit, and documentation states that the patient was lost to follow-up at this time. The ASCCP guidelines support clinical decision making in situations where patients have been lost to follow-up. Given the patients history of high-grade HPV followed by ASCUS testing, a one-year follow-up co-test is appropriate and consistent with standard therapy. Therefore, HPV testing performed on 9/29/20 was likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 66-year-old female enrollee has requested authorization and coverage for Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas obstructive sleep apnea. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. The patient has obstructive sleep apnea and has no nasal obstruction. She has not been able to tolerate continuous positive airway pressure therapy. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device, given the intolerance to continuous positive airway pressure therapy, anterior posterior collapse, no central apnea, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, Inspire upper airway stimulation system is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that intractable lower urinary tract symptoms and painful bladder/urethral syndrome related to interstitial cystitis can be clinically difficult to treat. Treatment options often are limited and have variable results. Patients often receive multimodal treatment, including proceeding to secondary and tertiary treatment options. Percutaneous tibial nerve stimulation is considered as a tertiary treatment option for intractable lower urinary tract symptoms and painful bladder syndrome with urgency frequency syndrome. There is some support for the requested services in this clinical setting. Therefore, nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 was likely to have been of greater benefit than other treatment options. 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: Experimental
Decision: Overturned

Summary Reviewer 1
A 49-year-old female enrollee has requested reimbursement for a digital breast tomosynthesis that was performed on 3/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for the enrollees breast examination The physician reviewer found there is limited peer-reviewed literature that supports the use of three dimensional breast tomosynthesis (DBT) over currently available techniques. Although DBT may be a promising technique, its clinical efficacy has yet to be substantiated as superior to currently available standard medical therapies in peer-reviewed literature.  Thus, the digital breast tomosynthesis portion was not likely to be superior to available standard modalities for evaluation of this patient. Based upon the information set forth above, the service at issue was not likely to be more beneficial than any available standard therapy for evaluation of the patient. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for corneal collagen crosslinking performed on 3/13/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees keratoconus. The physician reviewer found that there is strong evidence in the literature that collagen crosslinking can halt the progression of keratoconus. It is U.S. Food and Drug Administration (FDA) approved for this indication. Given the patients age, he is at significant risk for progression. Given his history of progressive blurriness, particularly in the right eye which had not yet undergone crosslinking, it highly suggests progression in the right eye. Therefore, corneal collagen crosslinking performed on 3/13/17 was likely to have been more effective than other available treatment options. 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 

A 50-year-old male enrollee has requested authorization and coverage for Korlym 300 mg tablets. 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 current medical evidence supports the requested medication in this clinical setting. Meningiomas are more commonly positive for progesterone receptors than for estrogen receptors. Several studies have been conducted on long-term oral therapy of unresectable meningiomas with the antiprogesterone mifepristone (RU486). In the study by Grunberg and colleagues, fourteen patients received mifepristone in daily doses of 200 mg for periods ranging from two to greater than 31 months (greater than or equal to six months in 12 patients). Five patients demonstrated signs of objective response (reduced tumor measurement on computerized tomography scan or magnetic resonance imaging, or improved visual field examination). Three patients experienced subjective improvement (improved extraocular muscle function or relief from headache). The side effects of long-term mifepristone therapy were noted to have been mild. The authors noted that long-term therapy with mifepristone may have efficacy in cases of unresectable benign meningioma. There is sufficient support for the requested medication in this clinical setting. Therefore, Korlym 300 mg tablets are medically necessary for the treatment of this patient.