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

Summary Reviewer 3


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 the medical evidence supports the services at issue in this patients case.  The medical literature suggests that treatment of the anterior accessory vein can lead to favorable hemodynamic changes in the treatment of venous insufficiency.  Providers may use endovascular techniques to treat an anterior accessory saphenous vein if it is straight enough to accept a treatment catheter. There are also providers who use Varithena for these procedures because the foam is able to travel in the branch if it is tortuous. The literature supports the use of ablation for treatment of the refluxing anterior accessory saphenous vein.  Thus, radiofrequency ablation of the right side performed on 5/25/16 was likely to have been of greater benefit than other treatment methods.  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: Upheld

Summary Reviewer 1


The parent of a 17-year-old male enrollee has requested reimbursement for intravenous treatment with antibiotics for Lyme disease from August 2015 through November 2015. 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 the patient presents for cognitive dysfunction and fatigue of long-standing duration.  The records do not include a positive IgG antibody titer.  The patient has had multiple courses of antibiotics, without lasting and significant improvement.  The diagnosis of late stage Lyme disease has not been established.  The treatment of late stage Lyme disease is a four-week course of intravenous antibiotic. Prolonged courses or repeat courses have not been shown to be efficacious.  All told, intravenous treatment with antibiotics for Lyme disease from August 2015 through November 2015 was not likely to have been of greater benefit 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: Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested authorization and coverage for L5-S1 decompression with lumbar fusion, possible transforaminal lumbar interbody fusion (TLIF) and associated three inpatient days. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees back pain. The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  A review of the literature indicates moderate evidence of good outcomes from standalone lumbar fusions for chronic pain with or without instability. In this case, there is evidence of severe chronic low back pain associated with disc space collapse at L5-S1 and degenerative retrolisthesis. There is also evidence of facet arthritis and moderate bilateral neural foraminal narrowing and some displacement of the left S1 nerve root. As such, decompression combined with a fusion procedure is medically necessary. The medical evidence supports the requested services in this clinical setting. Therefore, L5-S1 decompression with lumbar fusion, possible transforaminal lumbar interbody fusion (TLIF) and associated three inpatient days are medically necessary for the treatment of this patient. Therefore, the requested services are 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 52-year-old transgender female enrollee has requested reimbursement for CPT codes 67900, 20926, 21121, 40799, 30410, 21172 and 30520 performed on 10/15/19. 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 the submitted documentation supports the medical necessity of the services at issue. The records document that the patient has a history of gender dysphoria. The World Professional Association for Transgender Health (WPATH) position statement notes, non-genital surgical procedures...notably facial feminization surgeryare often of greater practical significance in the patients daily life than reconstruction of the genitals. Ainsworth and Spiegel reported that facial feminization surgery, like genital surgery improved mental health-related quality of life. There is sufficient support for the services at issue in this clinical setting. Therefore, CPT codes 67900, 20926, 21121, 40799, 30410, 21172 and 30520 performed on 10/15/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested authorization and coverage for anterior cervical discectomy and fusion surgery. 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 supports the requested services in this clinical setting. The records document a history of neck pain and radicular paresthesias in the upper extremities, left greater than right, in the C6 distribution, and imaging evidence corroborates the clinical findings. Epidural steroid injections provided short-term relief. The provider has recommended an anterior cervical discectomy and fusion at C5-6. Anterior cervical discectomy and fusion is one of the most common procedures performed in spine surgery. The indication is neck pain with a neurocompressive lesion, as in this case. It allows for a direct decompression of the spinal cord and the neural foramina. Various studies comparing anterior cervical discectomy and fusion with anterior plate fixation versus use of cages report superior surgical outcomes in anterior cervical discectomy and fusion procedures with anterior plate fixation and slightly better neck pain scores at last follow-up. There were no significant differences in the operative blood loss, clinical outcomes or rates of fusion between the two groups. The medical evidence supports the requested services in this patients case. Therefore, anterior cervical discectomy and fusion at C5-6 level is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 56-year-old male enrollee has requested reimbursement for DecisionDx Melanoma testing performed on 11/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases, with good correlation between DecisionDx-Melanoma testing class and prognosis in patients undergoing sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma testing date compares to the ten-year Balch data. Most importantly, it is unknown if it can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 11/14/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that the Latera implant is an absorbable material specifically designed to support the lateral nasal wall collapse in selected patients.  Currently, there is a lack of long-term objective data supporting the clinical advantage of the device, although there are some articles and anecdotal evidence that the device is useful. Stolovitsky and colleagues stated evidence for longer-term improvement in a prior cohort of patients examined at 12 and 24 months postoperatively provides hope that these results may be maintained for two years or more. Limitations of the study include a single arm study design with short-term follow-up. A randomized placebo control study design should be considered in the future. The current medical evidence has not demonstrated the superior efficacy of the requested services. Thus, vestibular stenosis repair is not likely to be more effective than other treatment options. 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: Overturned

Summary Reviewer 3

A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that contrast-enhanced breast MRI is approximately 90% sensitive for the detection of breast cancer in the high risk population, whereas ultrasound and mammography are approximately 38% sensitive individually in this population. Computer-aided detection is software that is used as part of the interpretation of the MRI, which helps to analyze the breast tissue and possible abnormalities. It is considered an integral part of the breast MRI examination. Screening contrast-enhanced breast MRI beginning at age 25 is recommended in women with BRCA gene mutations, their untested first degree relatives, and women with a lifetime risk of greater than 20%. MRI with mammography is recommended starting at age 30. This patient has a known BRCA2 gene mutation, which is considered one of the highest risk populations for breast cancer. In this setting, the medical evidence supports annual screening MRI examinations including computer-aided detection. Thus, computer-aided detection performed on 4/20/18 was likely to have been of greater benefit than 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: Overturned

Summary Reviewer 2

A 62-year-old male enrollee has requested reimbursement for homocysteine, Factor V Leiden and methylenetetrahydrofolate reductase (MTHFR) testing provided on 4/28/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees right lower extremity deep vein thrombosis (DVT). The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Homocysteine testing is clinically indicated for idiopathic or recurrent venous thromboembolism. In this case, the patient has de novo DVT without provocative factor per se, and is at high risk for pulmonary thromboembolism. In addition, Factor V Leiden genetic testing was clinically indicated given the patients venous thrombosis with a family history of thrombotic disease. Moreover, there is growing evidence that MTHFR gene polymorphism testing has utility in this clinical setting. As such, the homocysteine, Factor V Leiden and MTHFR testing provided on 4/28/16 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 3 
 
An 18-year-old male enrollee has requested reimbursement for outdoor behavioral health 
services provided from 11/03/20 through 12/31/20. The Health Insurer has denied this request 
and reported that the services at issue were investigational for the treatment of the enrollees 
medical condition. The physician reviewer found that in a document outlining principles of care 
for residential treatment, the American Academy of Child and Adolescent Psychiatry stated, The 
best place for children and adolescents is at home with their families. A child or adolescent with 
mental illness should be treated in the safest and least restrictive environment and needed 
services should be wrapped-around to provide more intensive home or community-based 
services. However, due to the severity of an individuals psychiatric illness, there are times when 
a patients needs cannot be met in a community-based setting. The Child and Adolescent Service 
Intensity Instrument (CASII; AACAP, 2007) defines level of service intensity by a combination of 
variables: clinical services, support services, care environment, crisis stabilization and prevention 
services. The Child and Adolescent Level of Care Service Intensity/Utilization System (CALOCUS-
CASII) provides a framework for determining the appropriate level of care for children and 
adolescents in mental health treatment. CALOCUS-CASII also sets parameters for the clinical 
services typically offered at each level of care.  According to CALOCUS-CASII, Level Five: Medically 
Monitored Intensive Integrated Services is the level assigned to most residential treatment 
centers. Per CALOCUS-CASII, This level of service intensity refers to treatment in which the 
essential element is the maintenance of a milieu in which the therapeutic needs of the child and 
adolescent  and  family  can  be  addressed  intensively.  CALOCUS-CASII  guidelines  state  that 
medical  and  psychiatric  services  should  be  available.  Additionally,  non-psychiatric  clinical 
services generally average 8-20 hours per client weekly.  Per the clinical records provided, the 
patient did not receive clinical services at this level of intensity while attending the outdoor 
behavioral  health  program  during  the  period  under  review.  Furthermore,  the  clinical 
documentation does not meet typical standards for residential care. There is no convincing 
explanation offered as to why the patient could not have enrolled in a standard residential 
treatment program instead of the outdoor behavioral health program. Additionally, there is no 
indication that the patient received unique benefits from the outdoor behavioral health program 
that he could not have received at a standard residential treatment facility. The discharge plan 
for the outdoor behavioral health program included a recommendation for the patient to 
transfer to a residential treatment program. Therefore, outdoor behavioral health services  provided from 11/03/20 through 12/31/20 was not likely to have been more beneficial than any 
available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 65-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 6/13/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who has a history of breast cancer. The physician reviewer found that digital mammography screening has been proven to decrease mortality related to breast cancer. Standard or two-dimensional mammography does have significant limitations, namely obscuration of cancers within areas of overlapping or dense tissue, as well as false positive recalls due to overlapping breast tissue, which must be confirmed with additional imaging. Digital breast tomosynthesis addresses both of these issues. The addition of breast tomosynthesis decreases the false positive recall rate by 15%. It does this by allowing the radiologist to scan through slices of breast tissue rather than seeing the breast tissue superimposed on itself. In sum, breast tomosynthesis performed on 6/13/17 was likely to have been of greater benefit than other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 45-year-old female with attention deficit/hyperactivity disorder (ADHD). The 
patient has requested authorization and coverage for brand name Adderall 20 mg tablets. The 
physician reviewer found that the submitted documentation supports the medical necessity of 
the requested medication. This patient was diagnosed with ADHD previously and has benefited 
from treatment with Adderall. Given the patients lack of misuse of the stimulant and benefit in 
her ADHD symptoms from this medication, there is support for the requested medication. 
Additionally, the patient has tried generic Adderall and had numerous adverse effects from that 
formulation, which she did not experience from brand name Adderall. This was reported in 
medical records. Therefore, brand name Adderall 20 mg tablets are medically necessary for the 
treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for laboratory testing (collagen crosslink testing) performed on 12/03/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has been diagnosed with osteoporosis. The physician reviewer found that markers of bone turnover, such as the collagen crosslinks, have been recognized by experts in osteoporosis as a tool to evaluate osteoporosis from diagnostic and therapeutic standpoints. There are multiple articles that show the value of this test with anabolic agents, such as Forteo, which is the medication that the patient is receiving. Antiresorptive agents decrease and anabolic agents increase the markers of bone turnover. These markers are useful to determine adherence and efficacy of therapy. This patient has received antiresorptive therapy in the past, so it is important to obtain a baseline of the markers of bone turnover. Subsequently, during therapy with Forteo, an anabolic agent, markers of bone turnover increase, and this elevation is associated to increases in bone density and therefore efficacy of therapy. Therefore, laboratory testing (collagen crosslink testing) performed on 12/03/16 was likely to have been more beneficial than any available standard test, and is an important component of monitoring therapy. 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 parent of a 15-year-old male enrollee has requested reimbursement for intensive outpatient program (IOP) services provided from 4/28/16 through 7/8/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse. The physician reviewer found that outpatient treatment and least restrictive options are considered first-lines of care as referenced by The American Academy of Child and Adolescent Psychiatry (AACAP), which recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. The documentation indicates that this patient had not been in any type of behavioral health therapy for the three months prior to the disputed stay. Prior to that treatment, the patient was in talk therapy and there was no indication that the patient was receiving outpatient substance abuse treatment to address his substance use, anxiety, or oppositional behaviors. The psychiatric admission evaluation indicates the patient was cooperative and did not demonstrate any suicidal or homicidal ideation. His thoughts were logical and he did not have any cognitive issues that would have prevented participation in outpatient behavioral health therapy for substance abuse treatment. The patient appeared to make progress in treatment. He was cooperative, calm and engaged actively in the IOP. He was able to verbalize improvement in his relationships with family as well as his some of his target symptoms. In large, the treatment progress notes were extremely vague. Outpatient therapy for cannabis use has shown benefit as noted by Gates and colleagues, who noted that those receiving psychosocial intervention used cannabis on fewer days compared with those given inactive control. All told, the IOP services provided from 4/28/16 through 7/8/16 were not medically necessary for treatment of this patients behavioral health issues. Based on the foregoing discussion, 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: Overturned

Summary Reviewer 1

A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical records support the superior efficacy of a portion of the services at issue. This patient sustained 15% total body surface area second-degree and third-degree burns on the perineum and feet. She was initially managed with dressing changes. The burns developed a thick eschar, and it was felt they were not adequately being managed with dressing changes. On 1/10/19, she underwent debridement of the 15% total body surface area second-degree and third-degree burns of the perineum, bilateral thighs, bilateral lower legs and left foot, including all toes. The debrided burn wounds were then covered with Suprathel skin substitute. Skin substitutes, such as Suprathel, offer the benefit of not requiring a host donor. Based on this benefit, skin substitutes offer benefits over traditional grafting strategies. The use of a skin substitute can also be used when there is uncertainty about the vascularity of the underlying wound bed and whether or not this would support the healing of a skin graft. The medical evidence supports the use of skin substitutes for partial thickness burns. In this patients case, Suprathel was used on both partial and full thickness burns. Therefore, the medical evidence supports the services at issue as it relates to the treatment of partial thickness burns. However, there is a lack of support for the services at issue for the treatment of this patients full thickness burns.