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

Summary Reviewer 1

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 current medical evidence supports the services at issue in this clinical setting. The patient has a history of high-risk HPV genotype 16. She has not been consistent with her follow-up. Recent changes in the American Society of Colposcopy and Cervical Pathology (ASCCP) guidelines have moved to a risk-based assessment for the management of cervical cancer screening. HPV testing is the preferred manner of assessing risk. In this case, because data is missing, the guideline algorithm recommends clinical judgment. 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: Upheld

Summary Reviewer 3

A 57-year-old female enrollee has requested reimbursement for DecisionDX-melanoma gene expression test performed on 8/12/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees left cutaneous melanoma. The physician reviewer found that the Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDX test for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There is also a lack of consistency between various genes being used as biomarkers. As such, the test is very novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the National Comprehensive Cancer Network (NCCN) guidelines. All told, DecisionDX-melanoma gene expression test performed on 8/12/16 was not likely to have been superior over other methods of evaluating this patients medical condition.Therefore, for the reasons stated above, the service at issue was 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 29-year-old female enrollee has requested authorization and coverage for Otezla 30 mg tablets. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis. The physician reviewer found the patients diagnosis of chronic plaque psoriasis requires systemic treatment. Psoriasis is a chronic inflammatory skin disease. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor (TNF) biologic therapies for the treatment of moderate to severe psoriasis have been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. On the other hand, Otezla does not increase the risk of malignancy, and it is approved by the U.S. Food and Drug Administration for treatment of psoriasis. Moreover, Otezla may be taken orally and is a therapeutic option for treatment of this patient. The physical limitations and risk of cancer/infection of injectable biologics, taken together with this patients family history of cancer, support Otezla for treatment of this patient.  For the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 39-year-old male enrollee has requested reimbursement for the surgery performed on 9/22/15. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational for treatment of the enrollees degenerative disc disease (DDD) with herniations.   The physician reviewer found the U.S. Food and Drug Administration (FDA) approval for the ProDisc-L total disc replacement states that this device is indicated for spinal arthroplasty in patients who are skeletally mature, have degenerative disc disease at one level in the lumbar spine from L3 to S1, have no more than grade 1 spondylolisthesis at the involved level, and have had no pain relief after at least six months of non-surgical treatment. The FDA indicates that this device should not be use in patients with isolated radicular compression syndromes, especially due to disc herniation. Yue and colleagues conducted a study 41 patients who underwent one-level versus two-level lumbar total disc replacement with five-year follow-up. The authors reported that the study was unable to identify statistical differences in all clinical and radiographical outcomes for patients who underwent one- and two-level ProDisc arthroplasty in a cohort from two centers. Delamarter and colleagues concluded, despite the relatively short duration of follow-up and design limitations, that two-level lumbar disc arthroplasty offers clinical advantages in terms of pain relief and functional recovery in comparison with arthrodesis. Longer-term follow-up is needed to determine the risks for implant wear and degenerative segment changes. Given the lack of peer-reviewed medical literature demonstrating superior health outcomes with total disc replacements with the ProDisc-L and Synthes devices, the surgery at issue was not 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 surgery at issue was 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 56-year-old female enrollee has requested reimbursement for inpatient length of stay provided on 8/17/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that vaginal bleeding secondary to a post-coital vaginal laceration, if severe, is managed through operative repair. Repair of vaginal lacerations usually requires surgical intervention and is best performed in the operating room to obtain adequate exposure. Regional or general anesthesia may be needed due to pain and pressure from retraction or extensive suturing. In this case, the repair was uncomplicated, with no extension beyond the vagina requiring further surgery. The patient tolerated the procedure well and was deemed stable postoperatively. Typically, patients are able to be discharged following the surgery from the ambulatory surgical unit, in which case inpatient admission is not medically necessary. In this patients case, she did not have any unique clinical circumstances that required acute inpatient admission. She was hemodynamically stable throughout her course and could have discharged after monitoring in the postoperative recovery unit. This patient did not require acute inpatient admission and could have been discharged after an appropriate period of monitoring in the recovery unit. Therefore, inpatient length of stay provided on 8/17/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of a three-year-old female enrollee has requested authorization and coverage for homocysteine, Factor V Leiden, and methylene tetrahydrofolate reductase (MTHFR), testing performed on 6/4/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee whose parent was diagnosed with idiopathic venous embolism and was positive for the MTHFR mutation and Factor V Leiden deficiency. The physician reviewer found that While there is some support for the services at issue, the studies do not show that these tests have a clinical benefit to normal healthy children, as in this patients case.  The majority of pediatric deep venous thromboembolisms occur in hospitalized children with underlying medical conditions, such as prematurity, cancer, congenital heart disease, and infection. Most have multiple risk factors, the single most common being the presence of a central venous catheter. Outcomes from testing in the pediatric population include these types of screening are only recommended when it may alter therapy or result in targeted thromboprophylaxis. These screening tests are used in certain patients, if indicated. However, in this patients case, she does not fall within the suggested clinical indications. Instead, the available literature appears to suggest that for generally healthy children, the best approach is to delay testing until children are older. As such, homocysteine, FVL, and MTHFR testing performed on 6/4/16 was not likely to have been more efficacious than standard therapies available for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 61-year-old male enrollee has requested authorization and coverage for radiofrequency ablation (code 50592). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records document a small, localized, renal cell tumor, for which surgical resection is the standard of care (likely, in the form of partial nephrectomy). This is stated in the National Comprehensive Cancer Network guidelines, and is justified by much higher local recurrence rates for radiofrequency ablation or microwave ablation as compared with resection. Therefore, the more minimally invasive approaches, such as radiofrequency ablation and microwave ablation, are reserved for patients who would not tolerate surgery, either by virtue of being poor surgical candidates, or for patients in whom removal of a kidney or part of it may result in renal failure. There is a lack of support for the requested services in this clinical setting. Thus, radiofrequency ablation is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 51-year-old female enrollee has requested reimbursement for hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees breast cancer. The physician reviewer found the superior efficacy of the services at issue has not been established. Hyperthermia is generally reserved for treatment of recurrent breast cancer to the chest wall after mastectomy. Whether the addition of hyperthermia to conventional external beam radiation therapy is of clinical benefit is unknown. At least six randomized trials have compared radiation therapy with and without hyperthermia in the setting of measurable breast cancer where local therapy was indicated and surgery not feasible. Most have not been published, and the trials had a number of weaknesses, including the fact that at least two were stopped before reaching target accrual, the eligibility requirements of all of the trials varied markedly, and the primary endpoint was complete local response rather than survival. Per the medical evidence, hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15 was not likely to have been more efficacious than other treatment options.  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: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 32-year-old male with a history of thoracic spine pain and T11-12 degenerative disc disease. On 12/22/17, the patient was treated with a bilateral T11-12 epidural steroid injection. Per the records, this provided good, but temporary, relief. The enrollee was also treated with physical therapy, chiropractic care, and massage. The provider has recommended transformational lumbar interbody fusion (TLIF). The patient has requested coverage for spinal fusion surgery. The Health Insurer has denied this request indicating that the requested services are 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 requested services. The 2009 American Pain Society guidelines indicate that spinal fusion surgery is not better than intensive rehabilitation for pain associated with degenerative changes (non-radicular). Per the medical records submitted, the patient does not meet this standard. The patient does not have radicular disease with neurological deficits, and he does not have spinal instability, fracture or tumor. Thus, the requested spinal fusion surgery is not medically necessary for the treatment of this patient. Therefore, the requested services 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 1

The parent of a 13-year-old male enrollee has requested reimbursement for balloon sinus ostial dilation performed on 10/28/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic sinus problems. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  This patient had chronic sinusitis. He underwent the standard of care treatment, which is adenoidectomy. A balloon sinuplasty procedure is a clinically effective procedure for pediatric patients suffering from chronic sinusitis. This has been proven in multiple trials.  All told, balloon sinus ostial dilation performed on 10/28/15 was likely to have been superior over 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested reimbursement for the emergency department services provided at Hoag Hospital on 12/1/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. The patients symptoms on 12/1/16 did meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. The patient was directed to go to the emergency department by her primary care provider to rule out diverticulitis. She was evaluated and found to have diverticulitis, was offered admission, and declined. She was prescribed oral antibiotics. The medical records support a comprehensive history and medical decision making of high complexity to support CPT code 99285. The patient then left and went to the second emergency department. There she received one dose of intravenous antibiotics and was discharged. All told, the emergency department services provided at Hoag Hospital on 12/1/16 were required on an emergent basis and include comprehensive history and medical decision making of high complexity to support CPT code 99285. Therefore, the Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a seven-year-old female enrollee has requested reimbursement for tonsillectomy and adenoidectomy performed on 9/25/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees sleep disordered breathing, recurrent tonsillitis, and adenotonsillar hypertrophy. The physician reviewer found that removal of tonsils and adenoids is a safe, effective surgical method to resolve breathing obstruction, throat infections and manage recurrent childhood ear disease. Tonsillectomy is performed commonly in combination with adenoidectomy, and has demonstrated efficacy as the primary treatment option for most children with obstructive sleep apnea syndrome. The medical literature suggests that obstructive sleep apnea syndrome is a risk factor for growth failure in children. A significant number of children with obstructive sleep apnea concurrent with growth failure are noted to benefit from tonsillectomy and adenoidectomy to recover and normalize their growth rate. This patient had clinically evident obstructive sleep apnea and growth failure as well as recurrent infections. Therefore, the tonsillectomy and adenoidectomy performed on 9/25/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 37-year-old female enrollee has requested authorization and coverage for escitalopram three tablets 20 mg daily. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the United States Food and Drug Administration (FDA) provides medication dose recommendations based on scientific data. The interpretation and application of these recommendations falls upon providers working directly with the patient population. This process allows for consideration of additional factors, such as provider experience, emerging treatment trends and clinical issues unique to individual cases, in the delivery of evidence-based, patient-centric care. As such, systematic medication titration is a core element of the art of medical practice and a key component to patient-centered care. Escitalopram is a potent and highly selective serotonin reuptake inhibitor (SSRI) that acts by binding directly to the serotonin transporter. Like other SSRI medications, escitalopram is a trusted intervention in the treatment armamentarium for those suffering from OCD. Providers have long recognized that the treatment of OCD often requires supra-therapeutic SSRI dosing. This practice is supported by the American Psychiatric Association (APA) clinical practice guideline for OCD which supports the occasionally prescribed maximum dose of escitalopram is 60 mg per day. Considering the medical records, community standards, endorsement from the APA and the peer-reviewed literature base, escitalopram 60 mg daily represents a safe, appropriate treatment consistent with good medical practice. The requested medication is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  As such, the requested escitalopram three tablets 20 mg daily are medically necessary for treatment of the patients behavioral health condition. Therefore, the requested medication is 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 55-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 11/2/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the American College of Radiology (ACR) has recommended tomosynthesis be removed from the investigational category due to the advantages it affords radiologists in interpreting mammograms. This tomographic method allows radiologists 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. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) imaging protocol was likely of greater benefit to the patient than 2D 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: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 60-year-old male. An echocardiography report dated 10/13/21 reported severe 
apical  hypertrophy,  reduced  strain,  and  an  apical  aneurysm.  The  patient  has  requested 
reimbursement  for  a  S-ICD  subcutaneous  cardioverter  defibrillator  from  12/9/21  through 
12/10/21. The Health Insurer has denied this request and reported the service at issue was not 
medically necessary for the evaluation of this patient. This denial is the subject of this appeal and 
determination. The physician reviewer found that the submitted documentation does not support the 
medical  necessity  of  the  service  at  issue.  In  the  setting  of  primary  prevention  implantable 
cardioverter defibrillator (ICD) placement, the usual indications for a subcutaneous defibrillator 
over a transvenous defibrillator include inadequate vascular access, anticipated multiple venous 
access procedures (for example, in the case of a patient with young age), previous cardiac infection, 
increased risk of infection, and existence of right-sided artificial heart valves that preclude 
transvenous lead placement. In this case, none of these indications are documented in the records 
provided and there is report of ventricular tachycardia that would not be able to be terminated by 
tachypacing, if needed, if a subcutaneous device were placed. Therefore, S-ICD subcutaneous 
cardioverter defibrillator from 12/9/21 through 12/10/21 was not medically necessary for the 
treatment of this patient.