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

Summary Reviewer 

A 26-year-old female enrollee has requested reimbursement for mental health partial hospitalization provided from 1/23/19 through 1/25/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 1 due to a lack of current suicidal ideation and no self-harming behaviors. In terms of functional status, the records support a score of 2 due to an overall good functional level with appropriate activities of daily living. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability, no chronic medical issues and no active substance use. In terms of level of stress of the recovery environment, the records support a score of 2 due to no mention of a stressful recovery environment. With regards to level of support of the recovery environment, the records support a score of 2 due to family support and availability of treatment resources. In terms of treatment and recovery history, the records support a score of 2 due to success in the treatment program with a good level of cooperation and stabilization of symptoms. With regards to engagement and recovery status, the records support a score of 2 due to cooperation in treatment and insight into her need for treatment. Therefore, the patient has a composite score of 13. This score correlates with low intensity community-based services. In sum, this patients presentation did not meet criteria for partial hospitalization program level of care during the disputed timeframe. Thus, mental health partial hospitalization services provided from 1/23/19 through 1/25/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 55-year-old female who has been diagnosed with cervical dystonia. The patient 
has requested authorization and coverage for J0585, Botox 200 unit vial and service code 64615 
x  4  chemodenervation.  The  physician  reviewer  found  that  the  submitted  documentation 
supports the medical necessity of the requested services. Cervical dystonia is one of the most 
common adult-onset focal dystonias. It is a movement disorder with symptoms of neck posturing, 
tremor, and/or pain. Although mostly considered benign, cervical dystonia can lead to significant 
disability. The treatment of choice for cervical dystonia is botulinum toxin injections, which are 
administered into neck muscles to cause denervation and relaxation of the abnormal neck 
posture. There is sufficient support for the requested services in this setting. Therefore, J0585, 
Botox 200 unit vial and service code 64615 x 4 chemodenervation are medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a two-year-old female enrollee has requested reimbursement for chromosomal microarray (CMA, CPT code 81229) testing performed on 1/26/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has had a history of breath holding episodes that have increased in it severity.   The physician reviewer found that the use of chromosomal microarray testing now plays a central role in the evaluation and diagnosis of children with global developmental delay, cognitive delay, and autism spectrum disorders. In a recent consensus article by Miller and colleagues, the following statement was made: available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with DD/ID (developmental delay/intellectual disability), ASD, or MCA. Further, our recommendation based on current evidence is to offer CMA as the first-tier genetic test, in place of G-banded karyotype, for patients with unexplained DD/ID, ASD, or MCA.  In this patients case, she has a history of seizure like activity following breath holding spells that were increasing in frequency despite treatment with antiepileptic medications. However, the submitted records do not raise a concern of autism or global developmental delay. Moreover, there was no physical examination evidence of dysmorphic features. Based on the current literature, chromosomal microarray (CMA, CPT code 81229)  testing performed on 1/26/16 was not likely to yield a diagnosis above and beyond what has been noted clinically. Therefore, the services at issue was not likely to have been more effective than other standard options available in the evaluation of this patients medical condition.  Based upon the information set forth above, the requested 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 10/21/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for treatment of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. However, in this particular patient, there were no problems to be resolved as the patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient for screening purposes. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to multiple prior mammograms. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 10/21/15 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 diagnostic procedure 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 20-year-old male enrollee has requested authorization and coverage for inpatient admission for lidocaine infusions for seven days. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees orthostatic headache. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of support in the medical literature for the requested services in this clinical setting. In this case, the patient was diagnosed with chronic headache of migraine type with positional component. There is a lack of controlled studies supporting the safety and efficacy for lidocaine infusions for treatment of the patients medical condition. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3
A 30-year-old female enrollee has requested reimbursement for Prometheus Anser ADA (84999) provided on 10/14/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees inflammatory bowel disease (IBD). The physician reviewer found that there is a lack of support in the medical literature as to the superior efficacy of the services at issue in this clinical setting.  In this patients case, Anser ADA was ordered to direct the management of the patients Crohns disease. However, the use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira (adalimumab) may experience loss of response, but the appropriate method for determination of the cause for loss of response is unclear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. The available data does not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab. A study by Yanai and Hanauer concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. As such, the clinical literature does not support the superior efficacy of Prometheus Anser ADA diagnostic test performed on 10/14/15 over standard options in 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

The patient is a 45-year-old male diagnosed with amyotrophic lateral sclerosis (ALS). In October 2013 the patient presented with onset of symptoms that started about a year before. The occupational therapy evaluation performed in June 2017 indicates he is maximum assistance to total assistance for many of his activities of daily living (ADLs) including toileting, eating, and bathing. The patient is no longer ambulatory, and needs moderate to maximum assistance with transfers. The patient shows no significant respiratory compromise or bulbar symptoms. The patient has requested authorization and coverage for edaravone (Radicava). The Health Insurer has denied this request as investigational. According to the documentation submitted for review, the patient presents with late stage ALS with marked disability and sparing of respiratory and bulbar function. He initially had slow progression but has had much more rapid progression over the past year and has minimal upper limb function, and is non-ambulatory. A phase III study showed efficacy in a selective group of patients with early disease and mild-to-moderate disability (Abe, et al). However, the phase III study was designed to maximize the likelihood of a clinical response, so the criteria for entry were skewed to take those patients who were most likely to benefit, and they did benefit. Given that the patient has already been treated with riluzole and a lack of other potential therapeutic options, treatment with Radicava is likely to be beneficial for treatment of the patients ALS than any available standard therapy.  Based upon the information set forth above, the requested medication 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 Reviewer 


A 20-year-old male enrollee has requested reimbursement for substance use disorder partial hospitalization program (PHP) services provided from 10/3/17 through 10/6/17. 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 the substance use PHP services provided from 10/3/17 through 10/6/17 were not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient was not a danger to himself or others, and he was not aggressive or violent. His post-acute withdrawal symptoms were not reported. There were no significant emotional, behavioral, or cognitive symptoms that would warrant continued PHP level of care. There was no high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would have prevented stepping him down to a lower level of care. He was medically and psychiatrically stable. He remained in partial denial about his problem with alcohol. There was no documentation of significant progress, change in medications, and change in treatment plan, or mental status examinations. He had support systems in place. The source of his anxiety and depression were not clear and did not appear to be addressed in the PHP treatments. Thus, the patients continued recovery efforts, and development of coping skills could have been accomplished in IOP level of care or outpatient. He was working on issues in DBT/CBT groups, which could have been provided on an outpatient basis. As such, the services at issue were not medically necessary for treatment of the patients medical condition. 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 2

A 22-year-old female enrollee has requested reimbursement for the blood testing (Prometheus Anser IFX) performed on 4/26/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the patient is a 22-year-old female with Crohns disease and ileocolonic disease with a stenotic ileocecal valve. The patient also has a history of perianal disease. The patient is maintained on infliximab monotherapy. On 3/2/16, the patient reported feeling well. However, her fecal calprotectin was elevated at 288 and recent magnetic resonance enterography demonstrated increasing disease activity. There was concern that the patients infliximab levels were inadequate. The patient underwent Prometheus Anser IFX on 4/26/16 and results demonstrated detectable levels of infliximab (8.7) and undetectable levels of antibody. The patient has requested reimbursement for blood testing (Prometheus Anser IFX) performed on 4/26/16. The Health Insurer has denied this request as investigational. This case highlights exactly why infliximab level measurement is often not helpful clinically and there is very low evidence for its use to guide clinical management. The records demonstrate that the patient has good trough level of infliximab and no antibodies. However, the patient has active disease so the decision was made to increase the dose of infliximab. In this clinical setting, even without Prometheus Anser IFX testing the same clinical decision would have been made. For the reasons provided, the blood testing (Prometheus Anser IFX) performed on 4/26/16 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 73-year-old male enrollee has requested reimbursement for targeted genomic sequence analysis performed on 5/30/19. 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 molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network guidelines strongly advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling was medically appropriate in this patients case. Therefore, targeted genomic sequence analysis performed on 5/30/19 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 16-year-old male enrollee has requested reimbursement for the comparative genomic hybridization (CGH) testing performed on 4/26/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for the enrollees dysmorphic facies and postural and kinetic tremor. The physician reviewer found the array-based CGH, also known as CMA, has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies. Until recently, it was a diagnostic test that was employed when the first-line investigation of karyotype returned normal. Subsequently, CGH has emerged as a first-line investigation. The yield of this test is estimated to be 8-17% and varies with the degree of cognitive impairment, the presence of dysmorphic features, and the presence of congenital anomalies. More recently, data have shown that actionable findings from chromosomal microarray justify its use (Coulter, et al). Based on the support in the peer-reviewed literature, the CGH testing performed on 4/26/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 70-year-old male enrollee has requested authorization and coverage for DecisionDx-Melanoma testing performed on 10/28/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDx-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. The National Comprehensive Cancer Network has not recommended its use in this clinical setting. At this time, DecisionDx-Melanoma does not appear likely to be of greater benefit than the available standard therapy. As such, DecisionDx-Melanoma gene expression test performed on 10/28/16 was not likely to have been more effective than the other methods 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 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 10/21/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for treatment of the enrollees risk for breast cancer.  The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 10/21/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the diagnostic procedure 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.