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

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for residential treatment services provided from 8/05/15 through 11/30/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. In terms of risk of harm, the records support a score of 2. The patient had some risk of harm.  He has a history of intermittent suicidal ideation and has a history of writing a suicide letter.  The patient denied any current or future suicide plans at the residential treatment center. With regards to functional status, the records support a score of 3.  The patient had moderate functional impairment during the dates of service at issue.  The patient was increasing his substance use of marijuana and was failing out of school. Per documentation, he did have struggles interacting with staff at the beginning of his stay at the residential treatment center.  In terms of comorbidity, the records support a score of 3.  The patient had comorbidities of concussions, chronic nausea and vomiting, and cannabis use. His chronic nausea and vomiting is thought to have led the patient to increase his substance use due to marijuana helping with his nausea and vomiting. The patients marijuana use has had a significant impact on his presenting problems. With regards to the patients recovery environment, the records support a score of 2 in terms of environmental stress.  The patient had a good relationship with his mother and father. In terms of environmental support, the records support a score of 2.  The patient has supportive parents who are willing to participate in treatment if asked to do so.  With regards to resiliency, the records support a score of 3. The patient had equivocal resiliency and response to treatment.  In terms of acceptance and engagement, the records support a score of 3. At the time of admission, the patient expressed his desire to be treated in a less restrictive environment. The patient was passive in his treatment and limited his interaction with the staff. Thus, the records support a composite score of 18. Based on these criteria, the patient would meet criteria for an intensive outpatient program and could have been treated in a less restrictive environment. The patient continued to need treatment, but this could have been accomplished at a lower level of care. Therefore, residential treatment services provided from 8/05/15 through 11/30/15 were not medically necessary for the treatment of this patient. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a five-year-old male enrollee has requested authorization and coverage for Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units. 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 PANS represents sudden onset of psychiatric symptoms, typically consistent with obsessive-compulsive disorder, following infection with a number of agents, including group A streptococcus and mycoplasma. This represents a broader variation of PANDAS. An article by Calaprice and colleagues noted that the majority of practitioners utilized both short-term and long-term courses of antibiotics, intravenous immunoglobulin, particularly for patients with immunoglobulin G (IgG) deficiencies, plasmapheresis, psychotropic medications, and psychotherapy. Complementary and alternative medicines, including gluten-free diet and homeopathic medications, were also utilized. The authors noted that intravenous immunoglobulin therapy was reported to have been beneficial in reducing PANS symptoms for many patients, but was most beneficial, and most enduringly beneficial, for the subset with IgG deficiencies. This patient has a history of recurrent sinopulmonary infections, with reproducible laboratory evidence of common variable immune deficiency. He also meets criteria for PANDAS/PANS. Based on the current standard of care for patients with this constellation of disorders, monthly intravenous immunoglobulin therapy as prescribed is medically appropriate. Therefore, Gammagard 20 gm infused every four weeks for one year, 40 units per dose for a total of 520 units is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 62-year-old male who presented with prostate cancer and underwent a radical prostatectomy in 2008. The patient has requested authorization and coverage for radiation therapy for prostate cancer. 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 this patients pathologic specimen reveals lymph node disease with no evidence of distant metastases. Due to the localized disease presentation, radiation therapy is indicated and is potentially curative. The radiation technique of intensity modulated radiation therapy is necessary due to the patient receiving prior radiation to the pelvic region. Intensity modulation in this setting is necessary to reduce the dose to the surrounding small bowel, which will reduce long-term toxicities from the treatment. As this is a relatively rare clinical presentation with nodal only relapse of prostate cancer, there is a lack of phase 3 studies or guidelines that specifically address treatment in this scenario. However, there are multiple large retrospective series that indicate that salvage radiation therapy in this setting can result in long-term cure rates with minimal toxicities.  Therefore, radiation therapy for prostate cancer is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign.  The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14 was likely to have been superior over other methods of evaluating this patient.  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: Experimental
Decision: Upheld

Summary Reviewer 3
A 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that the medical evidence to support the effectiveness of proton beam radiation therapy in this clinical setting is lacking.  National Comprehensive Cancer Network Guidelines do not suggest the use of proton beam for breast cancer. Although proton beam radiation therapy has been shown to be safe and effective for certain tumors that are adjacent to critical structures, there is insufficient clinical peer-review literature for supporting its use for the treatment of breast carcinoma. Also, the ASTRO emerging technology committee report does not include proton therapy for breast cancer. Instead, there are other established alternative therapies available such as conventional conformal or intensity modulated radiation therapy for treatment of breast cancer. These conventional methods have been shown to be safe and effective for the adjuvant treatment of breast cancers. All told, proton beam therapy for six weeks is not likely to be superior over the conventional methods for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This patient has C2 disease with symptoms and anterior accessory saphenous vein reflux. Standard of care supports treatment in this patients case.  Generally, the indications for treatment include pain or other discomfort, edema, varix hemorrhage, recurrent superficial phlebitis, stasis dermatitis, or ulceration.  The medical evidence supports treatment of patients with C2 disease.  Per the current evidence, radiofrequency ablation of the right side performed on 5/25/16 was likely to have been more efficacious 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 3
A 46-year-old male enrollee has requested reimbursement for collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees bilateral corneal ectasia. The physician reviewer found that the medical literature supports the efficacy of the services at issue in this clinical setting. Collagen crosslinking is a standard treatment for progressive keratoconus and ectasia after refractive surgery. It was approved by the U.S. Food and Drug Administration in 2016. There are many case series showing the efficacy in post Lasik ectasia. In order to determine if a patient is an appropriate candidate for collagen crosslinking, one must have evidence of progression, which can be based on refraction, keratometry, topography, or objective testing measures. In this patients case, the records from the patients provider noted evidence of progression. Given the likelihood of progression, collagen crosslinking of the cornea including removal of the corneal epithelial performed on 10/18/16 and 11/1/16 were likely to have been the most effective treatment option for this patient.
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: Upheld

Summary Reviewer 

A 49-year-old female enrollee has requested reimbursement and prospective authorization and coverage for mental health outpatient treatment provided from 4/19/18 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, a mental disorder is defined as a syndrome characterized by clinically significant disturbance in an individuals cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. According to the clinical information presented for this review, this definition of a mental disorder is not met per the documentation. The records do not document the medical necessity of the services at issue due to overall lack of support for the presence of a mental illness. Therefore, mental health outpatient services from 4/19/18 forward were not and are not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers especially in patients with extremely and heterogeneously dense tissue. Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done using two-dimensional imaging alone.  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: Experimental
Decision: Upheld

Summary Reviewer 1

A 31-year-old female enrollee has requested reimbursement for the collagen cross links, any method (CPT code 82523) provided on 1/10/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees left ankle pain status De Novo procedure for osteochondral lesion of the medial talar dome. The physician reviewer found that serum or urine collagen crosslinks or biochemical markers are unproven to assess risk of fracture, predict bone loss, or assess response to anti-resorptive therapy. The current medical literature shows there is evidence that standard methods for measuring bone turnover markers are sufficiently sensitive to reliably determine individual treatment responses. There is insufficient evidence from controlled studies that bone turnover marker measurement improve adherence to treatment or improve health outcomes by reducing fracture rate. All told, the collagen cross links, any method (CPT code 82523) provided on 1/10/17 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 service 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 30-year-old male with a history of extensive physical and emotional abuse dating back to childhood and a history of alcohol as well as drug abuse. He was currently not working as a private basketball trainer due to COVID-19 and associated restrictions. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a.
stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed.
In terms of risk of harm, the records support a score of 3. He has been involved in excessive use of substances. There was no suicidal or homicidal ideation.
With regard to functional status, the records support a score of 3. The patient had relationship problems as a result of his drinking. His relationship with his girlfriend had suffered, and there was strain with his mother as well. He was motivated to achieve stability in these relationships and was engaged in family therapy.
In terms of comorbidity, the records support a score of 3. He has insulin dependent diabetes mellitus. There was nothing in the notes to indicate that his blood sugars were unstable.
With regard to level of stress of the recovery environment, the records support a score of 3. He was unable to work due to COVID-19 restrictions and was financially dependent on his mother.
In terms of level of support of the recovery environment, the records support a score of 2. The patientas mother participated in treatment.
With regard to resiliency and treatment history, the records support a score of 3. The patient has had emotional problems since childhood and has struggled with substance use.
In terms of engagement and recovery status, the records support a score of 2. He had acceptance of his illness and was engaged in his treatment. He was motivated to get better.
Thus, the records support a composite score of 19. Intensive outpatient program level of care was medically indicated. Therefore, intensive outpatient program services provided from 7/15/20 through 10/08/20 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement for acute inpatient mental health treatment provided from 2/13/20 through 3/19/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4. The patient had a serious risk of harm, due to consistent deficits in ability to care for herself. With regard to functional status, the records support a score of 5. The patient had severe functional impairment as evidenced by severe weight loss due to refusal of food and nasogastric tube feedings, leading to dehydration and requiring medical hospitalization. In terms of comorbidity, the records support a score of 5 due to her medical status being compromised by food refusal. With regard to recovery environment, the records support a score of 3. The patient had a moderately stressful environment. The records noted serious illness for prolonged period, leading to months of hospitalization. In terms of environmental support, the records support a score of 2 due to her parents participation in treatment and treatment planning. With regard to resiliency and treatment history, the records support a score of 5. The records document persistence of symptoms despite past treatment at high levels of care for extended periods of time. In terms of treatment acceptance and engagement, the records support a score of 4. The patient refused medications and food and refused to cooperate with behavioral interventions. Therefore, the patient has a total score of 28. Due to severe functional impairment and severe comorbidity, the recommended level of care is medically managed residence-based services. This is consistent with the level of care offered in an inpatient setting. Therefore, acute inpatient mental health treatment provided from 2/13/20 through 3/19/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 63-year-old male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees liver cancer. The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The most recent National Comprehensive Cancer Network (NCCN) guidelines for colon cancer state that In patients with a limited number of liver or lung metastases, radiotherapy can be considered in highly selected cases. For small liver lesions, it is well-established that SBRT yields high rates of control. In addition, radiation techniques other than SBRT will not likely allow adequate dose escalation to sufficiently treat the tumor or provide adequate normal tissue sparing. For this patient, with a lesion near the hilum radiofrequency ablation (RFA) is not an option as the tumor cannot be sufficiently heated as the vascular flow dissipates the heat, and there is a risk of vascular trauma such that RFA is contraindicated and conventional radiation is likely to be less efficacious. Therefore, SBRT 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.