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

Summary Reviewer 2

A 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that there is support for the efficacy of the requested services in this clinical setting. The National Comprehensive Cancer Network (NCCN) guidelines support the use of PET scan in patients diagnosed with recurrent prostate cancer. The studies have shown the safety and efficacy of this technique in patients experiencing biochemical recurrence. Some patients have distant disease detected with this technique sparing patients side effects from treatment. As such, PET (CPT code 78813) scan is likely to be more beneficial than the available standard techniques for the evaluation of this patient. Therefore, for the reasons stated above, the requested services are 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 3


A 38-year-old male enrollee has requested authorization and coverage for cervical disc prosthesis.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found the submitted records fail to demonstrate the superior effectiveness of the requested services.  There are concerns regarding short-term and long-term potential complications of cervical total disc arthroplasty.  The potential long-term complications of cervical total disc arthroplasty include a lack of predictability of individual autoimmune response to metal and methyl methacrylate debris.  If revision is needed after total disc arthroplasty, there may be added difficulty when the devices are removed with resultant large defects requiring complex bone graft procedures.  Revision procedures will have to be performed through tissue which has undergone a fibrotic response with increased risks incurred during the surgical exposures. This patients relatively young age contributes to an increased likelihood of negative effects and long-term complications.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 32-year-old female with excessive daytime sleepiness with Epworth sleepiness score of 18/24. She had a sleep study showing no obstructive sleep apnea followed by a multiple sleep latency test (MSLT) which was consistent with idiopathic hypersomnia with sleep latency less than 8 minutes, but no sleep-onset rapid eye movement (REM). The patient has requested authorization and coverage for Sunosi 75 mg tablets. 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 Sunosi is a new wake promoting medication that has been approved by the U.S. Food and Drug Administration (FDA) to treat narcolepsy or hypersomnia secondary to residual obstructive sleep apnea. Sunosi is a promising treatment for excessive daytime sleepiness regardless of the cause. Idiopathic hypersomnia is a rare condition. Thus, there is a lack of studies evaluating the effects of Sunosi for the treatment of idiopathic hypersomnia. Sunosi is not contraindicated for idiopathic hypersomnia. Idiopathic hypersomnia shares the same symptoms with narcolepsy type 2, except MSLT shows no sleep-onset REM, which is a narcolepsy characteristic. The requested medication is likely to be as effective for the treatment of idiopathic hypersomnia as treating excessive daytime sleepiness secondary to narcolepsy or obstructive sleep apnea. This patient failed first-line treatment, which is modafinil, and responded to Sunosi 75 mg. There is support for the requested medication in this clinical setting. Therefore, Sunosi 75 mg tablets are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 22-year-old female enrollee has requested reimbursement for residential mental health treatment services provided from 9/16/15 through 10/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services in dispute were reasonably expected to improve the patients condition while appropriate care could not have been effectively delivered in a less restrictive setting at the time. Developmentally, the patient had an abysmal sense of self and had failed to achieve the developmental milestone of identity formation. As such, she endured rather chaotic role diffusion manifest by self-defeating cognitive schemas and cyclical maladaptive patterns of behavior. Complicating this underlying foundation was the presence of anxiety and substance use disorders that generated impairment across multiple domains including the areas of occupational, academic, social and family functioning. The patient had failed less restrictive interventions during the episode of illness and was evaluated for suicidality in the acute setting just prior to admission. She was unemployed and not in school. She had poor insight and strained family relations. She did not have a support network conducive to recovery in the outpatient setting.  The patient required treatment from behavioral health specialty providers. The patient engaged in active treatment, including dialectical behavior therapy and pharmacotherapy, in structured and supervised setting that forced her to safely confront her distorted cognitions and maladaptive coping skills. Further, both the setting and services were safe, appropriate and consistent with good medical practice, and the duration of care was well within typical community standards. Finally, the disputed service laid the foundation for a successful transition to a community-based after-care program to continue the recovery process. Thus, the services at issue were medically necessary for treatment of the patients medical condition. 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: Upheld

Summary Reviewer 3


A 68-year-old male enrollee has requested reimbursement for proton beam radiation therapy. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that based on the information submitted, there is a lack of sufficient rationale for the use of proton therapy in the treatment of prostate cancer. Proton therapy is not considered more beneficial than standard conventional radiation therapy in the treatment of prostate cancer. The patients episodic diarrhea in not a sufficient rationale for the use of proton therapy as it is unknown whether treatment with protons or photons would affect this condition.  Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Sheets and colleagues evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. According to the position statement by The American Society of Radiation Oncology (ASTRO) At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Given the lack of support by national guidelines and peer-reviewed literature, the proton beam radiation therapy was not likely to be more beneficial for treatment than standard photon therapy. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 41-year-old male who sustained a left brachial plexus injury in 2002 and has been noted to have severe distal loss of function despite extensive rehabilitation as well as attempts at surgical reconstruction. A myoelectric orthosis has been proposed in this case. The patient has requested authorization and coverage for a MyoPro device. The Health Insurer has denied this request noting that the requested device is investigational for the treatment of this patient. There is very limited support in the literature as to the superior effectiveness of the requested device in this patients case. Although there have been numerous articles in the literature supportive of the potential benefits of this treatment, a recent review by Nadi and Midha discusses the limited available data regarding its effectiveness. The authors conclude that this technology as to its efficacy remains uncertain, Overall, this procedure portends great promise but remains experimental. The future results of the other 11 patients in the study may provide further supporting evidence for the validity of this approach. Conversely, the longer period of follow-up may uncover the downsides of this approach that are still hidden in the shadow of early success. As such, there needs to be further studies before this device can be recommended as a standard option for individuals in this clinical setting. There is still a paucity of evidence in the literature as to its short and long term effectiveness. All told, the requested MyoPro device is not likely to be superior over the standard options available for treating this patients medical condition.  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 Reviewer 

A 22-year-old male enrollee has requested reimbursement for outpatient behavioral health services provided from 1/01/16 through 1/05/16. 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 submitted documentation fails to demonstrate the medical necessity of the services at issue.  On 12/22/15, the patients mood was stable, with no anxiety or depression.  He was sleeping well and denied cravings.  Therapeutically, he was focused on the conflicted relationship between his mother and grandmother.  On 1/01/16, the patient was described as insightful and motivated.  He was actively participating in his treatment.  His urine drug screen was negative.  He was medication adherent, which included quetiapine for insomnia.  He had good support from his grandmother.  In addition to his relapse prevention efforts, the patient was exploring his characterological organization and consolidating the grief from the death of his stepfather.  He was addressing long-term issues, but there was no evidence of an acute psychiatric syndrome, poorly controlled addictive illness or concerning environmental circumstances.  Further, the medical records did not include several documents critical to the review process, for example a psychiatric evaluation, psychosocial assessment, multidisciplinary treatment plan or interpretative summary.  In the absence of said documents, which typically detail the current status and impact of the illness, analyze the burden of relevant psychosocial stressors, review the outcome of prior interventions and articulate the need for the particular placement, the documentation does not establish that the treatment setting in dispute would have been more likely to improve the patients condition, prevent a more serious episode of illness or reduce morbidity than well-orchestrated community-based programming in a sober living environment.  All told, outpatient behavioral health services provided from 1/01/16 through 1/05/16 were 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 60-year-old female enrollee has requested authorization and coverage for 22870 and 22869 (insertion of stabilization device without compression). 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 this patient presents with chronic low back pain radiating down the left lower extremity. Functional limitations are reported in standing and walking tolerance. Clinical examination findings document positive straight leg raise, globally limited lower extremity strength, and decreased bilateral lateral leg sensation. There is imaging evidence at both L2/3 and L4/5 of mild disc bulge with mild spinal canal stenosis and no foraminal stenosis. There is imaging evidence of dextroscoliosis curvature centered at L4, which appeared to have increased since the last examination on 8/25/18. There is radiographic evidence of L4/5 anterolisthesis with no instability on flexion/extension x-rays. She has failed conservative treatment. Under consideration is a request for the Superion device at L4/5, although the requested CPT codes reflect a 2-level procedure. Current peer-reviewed literature does not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term, peer-reviewed outcome studies to support the safety and effectiveness of this device for this patients medical condition as discussed above. There is no compelling rationale presented as to why standard surgical decompression would not be indicated. U.S. Food and Drug Administration (FDA) indications have not been met, as there is no imaging evidence of moderate spinal stenosis. There is no clear evidence that there are no FDA contraindications for the Superion procedure. There is also no documentation of dual-energy x-ray absorptiometry (DEXA) scan findings to rule out osteoporosis, given the history of daily steroid use, which would place her at high-risk. Therefore, the requested CPT codes 22869 and 22870 (insertion of stabilization device without decompression) are not likely to be more beneficial for treatment of the patients medical condition than any standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 56-year-old male who has been diagnosed with cannabis use disorder, alcohol use disorder, and cocaine use disorder. The patient began smoking marijuana at age 14, drinking alcohol at age 17 and using cocaine at 25 years of age. Prior to admission, the patient was smoking cannabis, drinking 48 ounces of beer and snorting 1 gram of cocaine on a daily basis. The patient was treated previously with chemical dependency outpatient services for two to three weeks in 2016. He also participated in Alcoholics Anonymous and was prescribed escitalopram and amitriptyline. Due to the sequelae of substance use including deceptiveness, isolative behavior and relationship stress, the patient was admitted for detoxification on 1/28/17.  He successfully completed a phenobarbital taper and was directly transitioned to a residential treatment program.  The Health Insurer has denied reimbursement for inpatient residential treatment from 2/02/17 through 3/08/17.  Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient.  This denial is the subject of this appeal and determination. The submitted documentation fails to demonstrate the medical necessity of the services at issue. The medical records do not demonstrate the necessity of residential level of care following detoxification. Upon admission, the patient had a normal mental status examination. He had no acute psychiatric issues or medical comorbidity aside from hyperlipidemia. He desired balance and happiness. He was employed and valued spirituality.  He received his last phenobarbital on 2/01/17, at which time his vital signs were stable, and he had no tremor.  Aside from a brief course of outpatient services a year prior, during the episode of illness the patient had not engaged standard therapies such as anti-craving medications, sober living environments, intensive outpatient programming or partial hospitalization. This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate at the time. Thus, inpatient residential treatment from 2/02/17 through 3/08/17 was 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 patient is a 68-year-old male who has requested reimbursement for DecisionDx-Melanoma testing. The patient has requested reimbursement for DecisionDx-Melanoma testing performed on 11/23/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that the use of gene expression profiling (GEP) testing according to specific melanoma stage (either before or after sentinel lymph node biopsy) requires rather prospective investigation in large, contemporary datasets of unselected patients. Prognostic GEP testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision making in this group. Commercially available GEPs, such as DecisionDx-Melanoma, are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariate nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. It remains unclear whether this GEP profile is reliably predictive of outcome across the risk spectrum of melanoma. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular, to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Therefore, DecisionDx-Melanoma testing performed on 11/23/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that the medical evidence has not demonstrated the superior efficacy of the services at issue in this clinical setting.  There are three major therapeutic approaches to the management of apparently localized prostate cancer. These include radical prostatectomy, radiation therapy, and surveillance with no specific treatment.  Recommendations are made as to these options based on risk stratification, meaning an estimate of the risk for the future development of recurrence. The patients prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen, and pathologic features. Thus, patients essentially can be placed into four categories: very low-risk, low-risk, intermediate risk, and high-risk. Based on the records, this patient would be placed in a very low-risk category for which active surveillance would be a good option. A further refinement of prognostication is the use of gene panels, such as OncotypeDX. This is a 17 gene panel that is capable of predicting recurrence of prostate cancer after treatment (Cheville, et al; Cullen, et al).  However, this test has not been clinically validated (Moschini, et al). Moreover, it is particularly speculative as to whether it would be useful in this specific patient who was assessed with very low-risk disease. All told, service code 84999, OncotypeDX prostate cancer assay completed on 6/6/16 was not likely to have been more effective than the available treatment options 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 the 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 1

A 69-year-old female enrollee has requested reimbursement for lipoprotein (a) testing performed on 2/09/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrolleeas condition than any available standard therapy. The physician reviewer found that there is a lack of accepted clinical studies demonstrating that strategies to correct the residual risk potentially identified by novel lipoprotein testing, such as the advanced lipoprotein analysis performed in this patientas case, will further reduce cardiac risk. It remains unclear from the current literature that such testing adds significant actionable information to what is already known from a fasting lipid panel, despite significant cost. There is insufficient evidence to support the use of advanced lipoprotein analysis in clinical practice, particularly in individuals at low risk such as the patient. In this case, the records document a recent coronary calcium score of zero. Therefore, lipoprotein (a) testing performed on 2/09/21 was not likely to have been more beneficial than other available methods of evaluating this patient.