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

Summary Reviewer

The patient is a 31-year-old female with multiple medical problems who has had years of pelvic pain and dysfunctional uterine bleeding. The patient has tried conservative treatment with oral contraceptive pills, intrauterine device, progesterone, and Depo-Lupron. The patient received genetic counseling and indicates that she has no desire for future fertility. She has not had a surgical diagnosis of endometriosis; however, her clinical presentation is suggestive of endometriosis. Her provider has recommended hysterectomy as the best treatment option for the management of this patients symptoms.
The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. There is support in the documentation provided for the requested services in this clinical setting.  While this patient does not have a surgical diagnosis of endometriosis, her symptoms are strongly suggestive of endometriosis. The association between endometriosis stage at surgery and severity of pelvic symptoms has been marginal.  Thus, a diagnostic procedure would add little to the management of this patients pain. In this case, it is reasonable to assume that the patient has endometriosis.  Given the presumptive diagnosis of endometriosis, long standing pelvic pain with menstrual dysfunction and a lack of desire for future fertility, it is reasonable for the patient to proceed with definitive treatment of hysterectomy. This request is supported by the American College of Obstetricians and Gynecologists Practice Bulletin on endometriosis. Accordingly, based on the documentation provided as well as the medical literature, the requested hysterectomy for treatment of this patients medical condition is supported as medically necessary.  Therefore, based on the information noted above, the requested services are 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 43-year-old enrollee has requested reimbursement and prospective authorization and coverage for tobramycin/betamethasone/itraconazole compound from 7/25/16 and 8/3/16 and forward. The Health Insurer has denied this request indicating that the compounded medications were and are considered investigational for treatment of the enrollees chronic sinusitis. The physician reviewer found that the patient has history of chronic sinusitis and has had problems despite multiple medical therapies. The patient has undergone surgery and the provider has requested topical antibiotic/steroid/antifungal for treatment. However, the combination of tobramycin/betamethasone/itraconazole compound has not been found to be more efficacious than standard therapy of saline in treating chronic sinusitis. There is a lack of support in the medical evidence indicating the superior efficacy of the compounded medications over standard options. Saline irrigation is the standard of care in treating chronic sinusitis after surgery. In sum, tobramycin/betamethasone/itraconazole compound administered on 7/25/16 and 8/3/16 and forward was not and is not likely to be superior to the available standard options for treatment of this patient. Therefore, for the reasons stated above, the compounded medications were not and are not likely to have been 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 1


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 7/8/16. 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 the breast tomosynthesis performed on 7/8/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The advantage of tomosynthesis relates to the ability it allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone.
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 1


The parent of a 12-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intravenous immune globulin therapy. The Health Insurer has denied this request indicating that the services at issue were and are investigational for the treatment of the enrollees medical condition. The physician reviewer found IVIG treatment is clinically supported in this patients case. In the treatment of autoimmune encephalitis, studies support steroids, IVIG and plasma exchange as first-line treatment and second-line treatment with rituximab and cyclophosphamide. In many cases, this is followed by steroid-sparing agents in the long-term. Autoimmune encephalitis is a rare condition and randomized controlled therapeutic trial data are limited for autoimmune encephalopathy, due to its low prevalence and due to the heterogeneous group of disorders that fall under this heading, which require very different therapeutic approaches. Fortunately, autoimmune encephalopathy typically responds quickly and completely to steroid therapy alone; however, this patient has a steroid allergy. For patients who are intolerant of steroids, weekly IVIG is found to be effective. For these reasons, the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any standard therapy.Based upon the information set forth above, the services at issue were and are 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 31-year-old female enrollee has requested authorization and coverage for Avastin. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found central nervous system tumors are classified by the WHO based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV. Glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Most GBM tumors recur and then the treatment options are limited. In this case, the patient has had a recurrence. Avastin is medically necessary and approved by the U.S. Food and Drug Administration (FDA) for recurrent GBM (Cohen, et al). Its use in this clinical setting is consistent with FDA approval and strongly supported by medical evidence. Therefore, Avastin is medically necessary for treatment of the patients medical condition. For the reasons provided, 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 reimbursement for substance abuse subacute residential treatment center services provided from 10/27/13 through 12/01/13.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Upon admission, the patient had a normal mental status examination.  He was motivated to make total lifestyle changes and stay sober.  He had maintained 101 days of sobriety earlier in the calendar year.  He had supportive friends and family, and safe housing.  Although the patient had met with a psychiatrist, and also had therapy focusing on self-esteem and occupationally-based leadership struggles, there was no evidence in the record that the patient had engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate at the time.  All told, substance abuse subacute residential treatment center services provided from 10/27/13 through 12/01/13 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 64-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that the most National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer acknowledge ongoing studies but caution that there is no clear evidence supporting a benefit or decrement to proton therapy over [intensity modulated radiation therapy] IMRT for either treatment efficacy or long-term toxicity. To date, there is a paucity of compelling data to suggest that proton therapy is superior to or more beneficial than IMRT. The current standard of care for prostate cancer is to offer proton beam therapy only as a part of a clinical trial and not as a substitute for IMRT. Thus, the requested proton beam radiation therapy is not supported as 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 requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 47-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD).The physician reviewer found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient presents with documented GERD based on having developed Barretts esophagus. However, the records show that the patient has benefited to a significant degree from Dexilant treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in the clinical setting of Barretts esophagus must be approached with caution since LINX has not been adequately studied in patients with Barretts. Therefore, it cannot be concluded that LINX is likely to be more beneficial for treatment of the patients GERD than any standard therapy. All told, the request for the LINX procedure is 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 requested procedure 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: Overturned

Summary Reviewer 

The patient is a 65-year-old male with a history of history of acute respiratory failure, tracheostomy, ventilator dependent, dysphagia, seizure disorder, encephalopathy, hyperthyroidism, hyperglycemia, hyperlipidemia, polyneuropathy, and chronic obstructive pulmonary disease (COPD). The records indicate the patient was ventilator dependent with a tracheostomy and feeding tube secondary to a chronic seizure disorder status post brain surgery in March 2015. He was hospitalized in long-term care from 3/9/15 until 1/11/17. The patients provider and representatives report that the patient required skilled nursing care during this period. The patients representative has requested reimbursement for the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, the medical records provided for review demonstrate that the level of care the patient received from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17 were of a higher level than standard custodial care and were medically necessary. Throughout the records, there are numerous instances of documented skilled care and physicians orders for wound care, physical therapy as well as medical specialty consultations, laboratory and radiographic testing. This patient had a very complex, evolving combination of medical issues that required ongoing evaluation and skilled medical care. Review of the medical records indicates that the care he received during the disputed date ranges does not fit the definition of custodial care. The patient received skilled care that was medically necessary to treat his frail, evolving condition. Thus, the inpatient services provided at Goldstar and Beachwood Rehabilitations Centers provided from 10/30/15 through 1/10/16 and from 4/22/16 through 1/11/17 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  
The patient is a 47-year-old female who presented to her provider on 11/29/22. The records noted 
a diagnosis of Susac syndrome, currently treated with intravenous immunoglobulin (IVIG) and 
rituximab. The patient has requested authorization and coverage for Panzyga SOL 5 gm/50 mL. 
The Health Insurer has denied this request and reported that the requested medication is not 
medically necessary for the treatment of this patient. This denial is the subject of this appeal and 
determination. The physician reviewer found that the submitted documentation supports the 
medical necessity of the requested medication. Marrodan and colleagues describe Susac syndrome 
as an autoimmune disease affecting the endothelial cells, leading to symptoms of encephalopathy, 
visual disturbances, and sensorineural hearing impairment. Susac syndrome is commonly treated 
with immunosuppressive therapies such as corticosteroids, IVIG, Cellcept, rituximab, and/or 
cyclophosphamide. As patients treated with corticosteroids alone may initially respond well but 
later  relapse  spontaneously  or  following  a  decrease  in  corticosteroids,  IVIG  therapy  is 
recommended for all patients with Susac syndrome. In this case, the patient has a diagnosis of 
Susac syndrome and has demonstrated symptom improvement with IVIG treatments. The records 
indicate that the patient has tried and failed treatment with Cellcept and has derived minimal 
benefit with corticosteroid infusion and rituximab. Given that current medical literature supports 
the use of IVIG in the treatment of Susac syndrome, the requested medication is medically 
indicated. Therefore, Panzyga SOL 5 gm/50 mL is medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 57-year-old female enrollee has requested reimbursement for Afirma Thyroid FNA Analysis performed on 12/4/14. 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 although FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is suggestive of a benign nodule and can preclude such surgical procedures (Duick et al). In this case, the patient underwent an Afirma gene classifier analysis which was suggestive of a benign nodule, and she was able to avoid an unnecessary surgery. For the reasons provided above, the services at issue were 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 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 1

A 42-year-old male enrollee has requested authorization and coverage for Tremfya. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that Psoriasis is a chronic inflammatory skin disease. Patients typically present with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the 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 (anti-TNF) biologic therapies for the treatment of moderate to severe psoriasis has 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. The best-documented association is non-melanoma skin cancer with psoralen plus ultraviolet A therapy and cyclosporine. In addition, patients treated with anti-TNF drugs may develop adverse events, such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. Anti-TNF biologic therapies of psoriasis patients increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Tremfya has been recently approved by U.S. Food and Drug Administration for the treatment of adult patients with moderate-to-severe plaque psoriasis who are candidates for systemic therapy or phototherapy. Tremfya represents a promising therapy, providing an alternative mechanism of action with high efficacy and safety profiles, sustained total skin clearance, and rapid onset of effect in psoriasis patients. Therefore, Tremfya is likely to be superior over other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 40-year-old female enrollee has requested reimbursement for testing for inherited thrombophilic disorders performed on 10/19/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has a history of recurrent pregnancy loss and has tested positive for MTHFR mutation. Although this is cited by her provider as a risk factor for pregnancy loss, based on the current literature, it is unclear if MTHFR polymorphisms independently increase the risk of pregnancy loss. Diagnostic testing, including an immunology and thrombophilia work-up, is recommended for recurrent pregnancy loss. However, the minimum immunology work-up for women with recurrent pregnancy loss is measurement of anticardiolipin antibody (IgG and IgM) and lupus anticoagulant. Specifically in regards to thrombophilia testing, there is contradictory literature on the association between maternal inherited thrombophilia and recurrent spontaneous abortion occurring in the first trimester. Evaluation for an inherited thrombophilia can be considered in rare cases of recurrent, unexplained late fetal loss (after nine weeks of gestation) associated with evidence of placental ischemia and infarction and maternal vessel thrombosis. Based on the above information, there is a lack of clinical data to support the above work-up in this patient. Therefore, testing for inherited thrombophilic disorders performed on 10/19/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 31-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/11/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas 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 may add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who had undergone sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the assay can be used prospectively to make clinical decisions. National Comprehensive Cancer Network guidelines do not recommend the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma testing performed on 12/11/19 was not likely to have been more beneficial than other methods of evaluating this patient.