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

Summary Reviewer 

A 64-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b. The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. In conclusion, 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 3


A 64-year-old male enrollee has requested reimbursement for injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g., liquid) 500 mg from 11/2/15 through 11/6/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees anti-GM1 polyneuropathy and Sjogrens syndrome. The physician reviewer found that although IVIG is not a first line therapy for all patients with polyneuropathy, there is solid research evidence supporting its use for patients with chronic inflammatory demyelinating polyneuropathy, autoimmune neuropathies, and anti-GM1 neuropathies.  In this case, the patient had significant symptoms including impaired balance, numbness and pain.  In addition, the patient had a previously documented, very positive response to the IVIG treatment. Undertreated autoimmune neuropathies frequently cause significant disability, weakness, pain, and numbness.  To this end, the use of IVIG in this particular case was highly effective.  In sum, injection, immune globulin, Gammagard liquid, non-lyophilized, (e.g. liquid) 500 mg from 11/2/15 through 11/6/15 was likely to result in a superior clinical outcome when compared to other standard forms of therapy for treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 44-year-old female enrollee has requested reimbursement for AlloMap testing performed on 9/10/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollee, who is status post cardiac transplant.  The physician reviewer found this patient underwent cardiac transplantation on 6/19/13 followed by AlloMap gene expression profile testing on 9/10/14 to help assess for rejection.  In this circumstance, while endomyocardial biopsies have been the accepted standard for assessing rejection in patients with cardiac transplantation, gene expression profiling testing has shown promise in recent years.  Per the medical evidence, a strategy using AlloMap testing is an appropriate alternative to routine endomyocardial biopsies in stable patients at low risk for rejection who are six months to five years after cardiac transplantation.  This patient fits all of those criteria, and there is also documentation to support that the AlloMap test in question was performed in place of an endomyocardial biopsy rather than in addition to an endomyocardial biopsy.  All told, AlloMap testing performed on 9/10/14 was medically indicated for the evaluation of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 64-year-old female who has been diagnosed with vertebral artery high-grade stenosis. In a letter dated 3/15/18, the provider noted the patient had a right carotid occlusion and a high-grade stenosis of the left carotid artery. The patient had presented with several transient ischemic attacks with complaints of dizziness, headaches and blurred vision. On 2/27/18, she underwent a left internal carotid artery angioplasty and stenting. The cerebral angiogram also noted a high-grade stenosis of the right vertebral artery of 70%. The patient then underwent a computed tomography (CT) perfusion to assess the blood flow to the posterior fossa. The CT perfusion on 3/07/18 revealed a decreased blood flow to the right occipital lobe, secondary to her right vertebral stenosis.  The provider recommended right vertebral artery angioplasty and stenting. The patient has requested coverage for vertebral artery angioplasty. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  The current medical evidence has not demonstrated the superior efficacy of the requested services. Angioplasty may be indicated for patients with severe vascular disease as indicated by greater than 50% stenosis and when there is severe disabling claudication or other severe disability from ischemia, critical limb ischemia or atheroembolic phenomenon. It is also appropriate for patients who have other physiologic changes requiring intervention. This patient has greater than 50% stenosis and dizziness. However, the records failed to establish that the patient had severe claudication or other severe disabilities from ischemia, critical limb ischemia or atheroembolic phenomenon. The records failed to establish physiologic changes were present to require intervention. The medical literature does not support that the performance of a vertebral artery angioplasty is superior to medical management. Further clinical trials are needed to establish superiority over medical management. Therefore, the requested vertebral artery angioplasty is not likely to be of greater benefit 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: Upheld

Summary Reviewer 2

A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that eligible patient for LINX Reflux Management System must demonstrate typical gastroesophageal reflux disease symptoms, an abnormal pH study, partial response to daily proton pump inhibitor (PPI) therapy, and absence of a large hiatal hernia (greater than 3 cm) or severe esophagitis per SAGES technology and value assessment. This patient has a normal BRAVO pH study done on 2/25/21 with normal acid exposure time of 4.1, and normal DeMeester score of 12.0. The study noted a normal symptom association probability of 0 with chest pain and 65 with throat pain. Thus, the patient did not fulfill the eligibility criteria of an abnormal pH study for LINX reflux management system. Therefore, LINX Reflux Management System (code 43284) and associated inpatient bed day is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 41-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents status post L4-S1 lumbar laminectomy and fusion with persistent severe and debilitating bilateral sacroiliac joint pain. Significant functional limitations are documented in activities of daily living. Clinical examination findings have documented five positive provocative sacroiliac joint maneuvers, including flexion, abduction and external rotation (FABER) test, compression, thigh thrust, Gaenslens, and distraction, consistent with reported imaging evidence of degenerative changes of the sacroiliac joints. Detailed evidence of a long-term nonoperative treatment protocol trial and failure has been submitted. He has had over 75% temporary pain relief with sacroiliac joint injections, confirming the sacroiliac joints as the pain generator. There is no evidence of lumbar spine post-surgical hardware complications or significant neural compression that could be responsible for this patients ongoing pain and disability. The current medical evidence supports sacroiliac joint fusion in this patients case. In sum, the requested sacroiliac joint fusion is likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 29-year-old male enrollee has requested authorization and coverage for Subsys. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the medical literature does not support the requested medication in this patients case.  The records do not document why injectable pain relievers are not an option for this patient.  The medical evidence supports the use of many treatment options for patients with spinal cord injury that have not been discussed.  Furthermore, the treatment for neuropathic pain has not been exhausted within the documentation available for review.  Thus, Subsys is not likely to be more effective than other options for the treatment of this patient.  Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 45-year-old female enrollee has requested reimbursement for the hip arthroscopy with femoroplasty performed on 6/21/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees right hip pain.    The physician reviewer found that in the medical literature, Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. The authors reported that femoroacetabular impingement was a common pathologic disorder of the hip that caused pain and had been implicated in the development of early osteoarthritis in young adults. When nonsurgical treatment methods fail, surgical options were recommended, but there was a lack of long-term outcome data to support one method over another. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Nationally recognized evidence based medical guidelines recommend surgery for femoroacetabular impingement for patients with symptomatic hip pain and dysfunction resulting from a defined injury with duration less than 18 months, failure of a minimum of three months of conservative treatment, symptoms including decreased range of motion, limp, and/or sexual difficulties, physical findings of hip tenderness and increased pain with extremes or motion or crepitation, MRI and radiographs show classic pincer and/or cam lesions, absent or minimal arthritic changes and hip joint space greater than 2 mm and no subchondral cysts, and pain relief should be demonstrated with a diagnostic intra-articular anesthetic injection in questionable or borderline cases. In this case, the patient presented with low back pain, right hip pain, and right SI joint pain. Functional difficulty was reported in activities of daily living. Evidence of reasonable and/or comprehensive non-operative treatment protocol trial and failure was submitted. Clinical examination was reported to be generally consistent with hip impingement. However, there was no corroborating x-ray or imaging evidence. Pelvic MRI documented no osseous or soft tissue abnormality. Right hip MR arthrogram demonstrated tearing versus sub-labral sulcus of the right acetabular labrum anteriorly with no osseous pathology. Overall, the evidence based medical criteria were not met for the right hip arthroscopy with femoroplasty performed on 6/21/17 given the absence of corroborating imaging evidence of a cam or pincer lesion, and ongoing signs or symptoms of lumbar radiculopathy and right SI joint dysfunction. All told, the hip arthroscopy with femoroplasty performed on 6/21/17 was not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 38-year-old female. The patient has requested authorization and coverage for 
nasal/sinus  endoscopy  with  maxillary  antrostomy  and  total  ethmoidectomy.  The  physician 
reviewer found that at issue is whether nasal/sinus endoscopy with maxillary antrostomy and 
total ethmoidectomy is medically necessary for the treatment of this patient. The submitted 
documentation supports the medical necessity of the requested service. The American Academy 
of Otolaryngology notes that the clinical indicators for endoscopic sinus surgery include chronic 
rhinosinusitis without nasal polyps with persistent symptoms and objective evidence of disease 
by endoscopic and/or CT imaging that is refractory to optimal medical treatment. In this case, 
the records document that the patient has chronic sinusitis and has failed optimal medical 
therapy with abnormalities seen on CT of the sinus. In this clinical setting, the requested surgical 
intervention is medically indicated. Therefore, nasal/sinus endoscopy with maxillary antrostomy 
and total ethmoidectomy is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the requested medication in this patients case. This patient has not demonstrated clinical evidence for neuroborreliosis. She has no neurologic findings. There is no abnormal cerebrospinal fluid, imaging or serology consistent with neuroborreliosis. The patient has received a four-week course of ceftriaxone, which is the standard course. Repeated or long-term therapy has not been shown to be efficacious. The treatment of Babesia is not with ceftriaxone, and Brucella is not a pathogen that is treated with ceftriaxone. All told, the requested intravenous ceftriaxone is not likely to be superior over other available treatment options.  Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a 14-year-old female enrollee has requested authorization and coverage for lidocaine injection 10 mg and associated inpatient stay. The Health Insurer has denied this request and reported that the requested services and requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Lidocaine infusions have been used in the adult population for years, and more recently have crossed over to the adolescent population with chronic pain. Studies of parenteral lidocaine for refractory chronic pain have demonstrated tolerability and efficacy. Parenteral lidocaine has been studied in adolescent patients with status migraine, and in appropriately chosen patients, has demonstrated both safety and efficacy. This treatment is not intended as a first-line approach to migraine pain. It is reserved for patients who have tried and failed numerous other treatment modalities. This patient has utilized multiple medications, lifestyle changes, complementary therapies and inpatient infusions, all without relief. Thus, lidocaine injection 10 mg and associated inpatient stay are likely to be more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested authorization and coverage for Remodulin (treprostinil) injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pulmonary arterial hypertension. The physician reviewer found that there is support in the medical literature and guidelines for the requested medication in this clinical setting. Remodulin (treprostinil) belongs to the Prostacyclin analog drug class. Based on recommendations from the 2015 European Society of Cardiology (ESC)/ European Society of Cardiology (ERS) guidelines for the diagnosis and treatment of pulmonary hypertension, Prostacyclin analogues are appropriate therapy in particular combination with phosphodiesterase inhibitors and endothelin receptor antagonists. In a study by Simonneau and colleagues, the effects of treprostinil in PAH were assessed in a randomized clinical trial. These patients showed improvements in exercise capacity, hemodynamics and symptoms. Some of the evidence from combination therapy indicate a reduced risk of clinical worsening and other significant endpoints. According to the submitted record, this patient has stabilized with reductions in pulmonary artery pressures and symptoms on her current regimen of combination therapy, which includes subcutaneous infusions of treprostinil. For these reasons, Remodulin (treprostinil) injections are medically necessary for treatment of this patients medical condition. Therefore, based on the above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 52-year-old male enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of supporting documentation provided for review, such as the patients IgE level, eosinophil level, and allergy testing results. In addition, there is a lack of documentation demonstrating that alternative treatments such as Nucala, Xolair or lifestyle changes would be more effective. For the reasons stated, bronchoscopic thermoplasty has not been established as medically necessary for treatment of the patients medical condition.  Given the above reasons, 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


A 43-year-old female enrollee has requested reimbursement for the screening digital breast tomosynthesis performed on 6/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 6/17/16 was likely to be more beneficial for evaluation of this 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for Anser ADA diagnostic testing performed on 2/18/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Anser ADA diagnostic testing performed on 2/18/15 was likely to be more effective for this patient than other available treatment options. There is clinical evidence from observational studies, cohort studies, controlled trials, and meta-analysis in the peer-reviewed medical literature sufficient to support the Anser assay in this clinical setting. In this case, the patient has Crohns disease and has been maintained on adalimumab. However, she developed mild diarrhea with lack of clear endoscopic evidence of recurrence. Hence, while on adequate therapy, ADA diagnostic testing was performed to check for developing adalimumab failure due the development of antibodies, versus subtherapeutic levels versus failure that would necessitate considering alternate therapy. Thus, the indication for the ADA test was the patients Crohns disease and potential developing flare despite being on adequate treatment with adalimumab, as well as ruling out alternate causes complicating her course. For the reasons provided, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, 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.