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

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who reported a history of urgency and frequency. The physician reviewer found that there is evidence from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up, and the long-term efficacy of percutaneous tibial nerve stimulation is largely unknown. American Urological Association guidelines recommend behavioral therapies (e.g., bladder training, bladder control strategies, pelvic floor muscle training, and fluid management) as first-line therapy to patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral antimuscarinics or oral beta 3 adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification, different anti-muscarinic medication or a beta 3 adrenoceptor agonist may be tried. Botox injection is a standard third-line therapy and is graded better. Percutaneous tibial nerve stimulation has not been proven to be superior to other alternatives. Studies have compared percutaneous tibial nerve stimulation to anticholinergics and have demonstrated comparable efficacy. As such, the superior efficacy of nerve stimulation treatment provided on 3/12/18, 4/10/18 and 6/12/18 has not been established. 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 
The parent of a nine-month-old male enrollee has requested reimbursement for cranial remolding orthosis provided on 6/5/15. The Health Insurer has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollees occipital flattening/plagiocephaly. The physician reviewer found that the American Academy of Pediatrics (AAP) guidelines, on cranial orthotics, state that cranial remolding orthosis is reserved for severe deformities and is not medically indicated for mild to moderate deformities. The AAP also noted that the use of cranial remolding orthosis may be used to confirm the diagnosis and to direct the subsequent management and treatment. Management and treatment of this condition may include molding helmets or surgery. Additionally, referral to a physical therapist may be considered if torticollis does not improve with neck stretching exercises within two to three months. A study by Lipira and colleagues looked at positioning and molding helmets. Their results revealed the following: the helmeted group had a larger reduction than the repositioned group in both maximum (4.0% versus 2.5%; P = .02) and mean asymmetry (0.9% versus 0.5%; P = .02). The greatest difference was localized to the occipital region. Another important facet to consider is the developmental outcome of the infant. Miller and colleagues looked to see if there was an increased rate of later developmental delay in school-aged children who presented as infants with deformational plagiocephaly, without obvious signs of delay at the time of initial evaluation. They concluded that infants with deformational plagiocephaly comprised a high-risk group for developmental difficulties presenting as subtle problems of cerebral dysfunction during the school-age years. In this patients case, he was diagnosed with severe plagiocephaly. The AAP guidelines as well as the medical literature support the use of cranial remolding orthosis for treatment of this patient. Therefore, for the reasons stated above, the equipment at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
The parent of a five-year-old male enrollee has requested reimbursement for immunoglobulin G 
(IgG) food testing performed on 9/27/21. 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 IgG food testing is not considered to be 
a clinically useful, relevant, or valid method for evaluating for food allergy or food intolerance. 
Lavine and colleagues noted, Making the diagnosis of a specific food allergy may include the 
following: a full medical history, physical examination, skin prick testing, carefully selected food-
specific IgE levels and oral food challenges to suspected food allergens in some instances. Per 
the authors, Research from the early 1980s reported a potential mechanism for IgG4 to trigger 
basophil histamine release, suggesting a role in the allergic response. Subsequent research 
clarified that this relation was not limited to IgG4 and in fact involved IgE-receptor cross-linking 
through a receptor complex found on the basophil membrane. This supports clinical observations  that neither total IgG nor IgG4 levels correlate with food allergy as shown on double-blind 
placebo-controlled food challenges. The authors stated, Physicians should caution patients 
about the controversy surrounding testing for food sensitivity. Recent position papers from 
European and American allergy and immunology societies have emphasized the limitations and 
potential misuse of IgG4 testing, indicating that these tests are not appropriate for making a 
diagnosis of food allergy.  Updated guidelines for the diagnosis and management of food allergy 
list food-specific IgG4 measurement as an unstandardized and unproven procedure, along with 
other tests such as hair analysis, cytotoxicity assays or electrodermal (Vega) testing. Sampson 
and colleagues noted, Unproved tests, including allergen-specific IgG measurement, cytotoxicity 
assays, applied kinesiology, provocation neutralization, and hair analysis, should not be used for 
the evaluation of food allergy. In sum, there is a lack of support for the services at issue in this 
clinical setting. Therefore, IgG food testing performed on 9/27/21 was not likely to have been 
more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 57-year-old male enrollee has requested reimbursement for Oncotype DX testing Prostate Cancer Assay provided on 9/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees elevated prostate specific antigen (PSA). The physician reviewer found that the gene expression analysis, such as Oncotype DX utilized to guide management of prostate cancer remains controversial at this time. Oncotype DX testing has not been validated with prospective randomized clinical trials. There is a lack of evidence from well conducted prospective clinical trials demonstrating that the utilization of Oncotype DX has an impact on patient health outcome. Therefore, the Oncotype DX testing provided on 9/15/15 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 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 

The guardian of a 15-year-old male enrollee has requested reimbursement for mental health inpatient treatment from 4/21/18 through 4/27/18. 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 that the submitted documentation supports the services at issue in this clinical setting. Per the provided documentation, the patient remained symptomatic from 4/21/18 through 4/27/18.  He was noted to have irritable mood at times and frequently reported anxiety and agitation, which required chlorpromazine as needed.  He often required behavioral redirection from hospital staff. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for youth (AACAP, 2014). The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  Based on the patients history and clinical status as outlined above, the patient met CASII service intensity criteria for secure 24-hour service with psychiatric management (AACAP). The patients clinical status, in addition to current medical literature, support that the mental health inpatient treatment from 4/21/18 through 4/27/18 was medically necessary for the treatment of this patients medical condition (AACAP; Okado et al; Van Alphen et al).  Therefore, for the reasons stated above, 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 

The patient is a 59-year-old female with a history of metastatic neuroendocrine pancreatic tumor. She is status post distal pancreatectomy, splenectomy, partial hepatectomy as well as radiofrequency ablation of hepatic metastases in February 2018. The physician reviewer found that Peptide receptor radionuclide therapy can be an effective treatment option for certain neuroendocrine tumors, improving progression-free survival. However, the treatment response is variable. Gallium dotatate PET/CT imaging has become a standard for the monitoring of certain neuroendocrine tumors, specifically somatostatin receptor imaging, and can help to identify patients in whom peptide receptor radionuclide therapy would be more effective. Gallium dotatate highlights the presence of somatostatin receptors in tumors, the entity to which the peptide receptor radionuclide therapy binds. It has been shown that baseline uptake on pre-treatment PET/CT predicts response to radionuclide therapy. In this case, the patient has failed traditional chemotherapy, evidenced by disease progression. She has been identified as a possible candidate for peptide receptor radionuclide therapy, and her provider recommended PET/CT prior to initiating treatment. There is sufficient support for the requested services in this clinical setting. Therefore, PET scan with CT for attenuation is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 47-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/24/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American College of Radiology (ACR) statement on breast tomosynthesis has urged that tomosynthesis be removed from the investigational category due to the marked advantages it brings radiologists in the interpretation of mammograms resulting in a decrease in callbacks and increase in detection of small cancers. In addition, tomosynthesis is approved by the U.S. Food and Drug Administration (FDA) for clinical use. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) protocol was likely of more benefit to this patient than had the exam been done with 2D technique only. 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 

A 48-year-old female enrollee has requested authorization and coverage for Stelara (ustekinumab injection) 45 mg/0.5 mL. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees psoriasis and psoriatic arthritis. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient is requesting coverage for Stelara for treatment of psoriasis and psoriatic arthritis. She has tried and failed therapy with topical steroids, tar topicals, methotrexate, ultraviolet B (UVB) light therapy, Enbrel for 13 years, and Humira for 10 years. The Health Insurer has denied reimbursement for the requested medication because the patient has not yet tried and failed therapy with Cosentyx. In this patients case, there are no documented contraindications to the use of Cosentyx which is approved for the treatment of psoriasis and psoriatic arthritis. Given that the preferred formulary medication is effective for the condition to be treated and there are no contraindications to its use, the requested medication is not medically indicated as there are efficacious alternatives available. Thus, Stelara (ustekinumab injection) 45 mg/0.5 mL is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 44-year-old male has requested authorization and coverage for total disc arthroplasty at the levels of L4-L5 and L5-S1. 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 the FDA approval for the ProDisc-L total disc replacement states that approval expands the indications for use of the ProDisc-L to include treatment of up to two consecutive lumbar spinal sections (levels) from L3-S1. Zigler and colleagues concluded that patients undergoing both ProDisc-L total disc replacement and circumferential arthrodesis for the treatment of single-level degenerative disc disease maintained significant improvement during the five-year follow-up. The total disc replacement group had significantly better improvement on some scales. The authors concluded, aAlthough total disc replacement patients avoid the stiffness of fusion and are more satisfied than fusion patients, both fusion and total disc replacement are reasonable surgical options in this specific patient population.a Siepe and colleagues concluded, aThe subjective outcome evaluation indicates that total disc replacement is a viable treatment option even in advanced stages of degenerative disc disease in the absence of other contraindications, in particular facet joint arthropathies.a This patient presents with persistent and ongoing low back pain. He continues to have severe low back pain impacting his function. Range of motion is restricted and painful. The submitted documentation demonstrates subjective and objective deficits that are corroborated by imaging studies. Trial and failure of conservative treatment modalities have been documented. Therefore, total disc arthroplasty at the levels of L4-L5 and L5-S1 is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested authorization and coverage for applied behavioral analysis (ABA) services for 30 hours per week. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees autism spectrum disorder. The physician reviewer found that this patient is reported to be on the autism spectrum. However, the records provided for review do not provide details regarding the frequency of challenging behaviors, nor his response to previous ABA therapy. Some of the goals being addressed in the proposed ABA therapy plan provided are more consistent with goals addressed with occupational or vocational therapy than directly addressing the patients autism spectrum disorder. These goals include completing chores and using utensils. In the medical literature, Orinstein and colleagues reviewed the intensity of ABA therapy required for optimal outcomes in children with autism spectrum disorder and found no correlation between the number of hours provided per week and outcomes. The authors noted that the age at which ABA therapy was started and duration of treatment was correlated with outcome. Luiselli and colleagues reached similar conclusions. Thus, the Health Insurers approval for 15 hours per week of direct ABA therapy is appropriate to address this patients current needs as documented in the records reviewed. Accordingly, the requested ABA services for 30 hours per week is not supported as medically necessary. Based on the foregoing discussion, 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: Upheld

Summary Reviewer 2

A 68-year-old female enrollee has requested reimbursement for carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees vulvar atrophy. The physician reviewer found in this case, there is a lack documentation that standard available therapies were sufficiently tried, nor were they contraindicated, before proceeding with the Mona Lisa Touch Laser treatment. In addition, the laser therapy used is not currently U.S. Food and Drug Administration (FDA) approved for the stated indication. Thus, the carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17 were 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 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 49-year-old male enrollee has requested reimbursement for the platelet rich plasma injection performed on 1/4/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees left foot pain. The physician reviewer found there is a lack of peer-reviewed literature supporting the use of PRP injection for the treatment of foot pain. Vannini and colleagues reviewed the medical literature on the clinical application of PRP for the treatment of foot and ankle pathologies. The authors found no clear indications for using PRP in the foot and ankle. For the reasons provided, the PRP injection provided on 1/4/17 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 service 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: Overturned

Summary Reviewer 


A 58-year-old female enrollee has requested reimbursement for anesthesia services provided on 6/14/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for treatment of the enrollee, who underwent a colonoscopy. The physician reviewer found the submitted documentation demonstrates the medical necessity of the services at issue in this clinical setting. This patient received propofol for sedation. The U.S. Food and Drug Administration package insert for propofol specifically states monitored anesthesia care, propofol should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure". Therefore, the presence of a separate provider for anesthesia is required. The current medical evidence supports the services at issue in this clinical setting. All told, anesthesia services provided on 6/14/17 were medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 32-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees asthma.  The physician reviewer found that the records and peer-reviewed medical literature suggest that this patient may benefit from the requested bronchial thermoplasty. The procedure was approved by the U.S. Food and Drug Administration (FDA) in 2010 for the treatment of severe persistent asthma in adults not well controlled with inhaled corticosteroids and long acting beta-agonists. The literature shows that bronchial thermoplasty would be beneficial to this patient in decreasing the number of exacerbations requiring prednisone orally, the need for rescue treatment such as albuterol, and improving her daily symptoms. The treatment has been shown to be safe up to five years after treatment per AIR 2 trial (Castro, et al). This patient meets the criteria with severe persistent asthma uncontrolled by maximal medical treatment. In addition, no other pulmonary condition is documented to explain her condition other than bronchial asthma and her pulmonary function tests fall in the category of moderate obstructive airway obstruction. For these reasons, the requested bronchial thermoplasty is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested procedure 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.