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

Summary Reviewer 

The patient is a 29-year-old female with a history of injury to the lower back while cheerleading, with associated chronic low back pain. The patient has requested authorization and coverage for lumbar spinal surgery at L5-S1 and one inpatient day. The Health Insurer has denied this request indicating that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that degenerative lumbar pathologies are commonly encountered at the lumbosacral junction. These include disc degeneration, ligamentum flavum hypertrophy, neural foraminal stenosis, and other causes of pain or neurologic deficit with associated radiculopathy. Conservative treatment should be tried first, as in this case. When conservative fails, surgical intervention at the lumbosacral junction becomes necessary. Surgery consists of decompression and stabilization of the level involved to maximize pain relief and relieve neural compression and reverse the radiculopathy, while maintaining the strength, function, and stability of the spine, and preventing adjacent level degeneration. In this case, there is documented failure of conservative treatments, including physical therapy and corticosteroid injections. As such, surgery is necessary. Documentation indicates the pain generator is L5-S1. Surgery has a good prognosis, and she is a good candidate. Therefore, the requested lumbar spinal surgery at L5-S1 and one inpatient day are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 2 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The  physician  reviewer  found  that  the  American  College  of  Obstetricians  and  Gynecologists 
(ACOG) recommends ultrasound examination for all pregnant patients. The timing and frequency 
depend on the indication for the examination. If a single screening examination is performed, the 
optimal time is at 18 to 20 weeks of gestation. This represents a time when fetal development and 
current ultrasound technology allow for the optimal detection of fetal anomalies. Additional 
important information from this examination includes assessment of the placenta and umbilical 
cord such as the location and placenta accreta spectrum, confirmation of singleton gestation or 
diagnosis of multiple gestation, assessment of cervical length  and screening for short cervical 
length, and assessment of fetal growth. If two screening examinations are performed, the first is 
typically done in the first trimester, either at seven to ten weeks of gestation for reliable assessment 
of pregnancy dating or, in settings of expertise, at 11 to 14 weeks for nuchal translucency 
examination, pregnancy dating, and an early fetal anatomic survey. Increased nuchal translucency 
is a marker for some aneuploidies and genetic syndromes, congenital heart disease, and some 
noncardiac anomalies. In either time period, the first trimester examination also assesses cardiac 
activity, number of fetuses, and chorionicity and amnionicity if there are multiple gestations. The 
second screening examination is performed in the second trimester at 18 to 20 weeks should be 
performed on all pregnant patients for a fetal maternal evaluation of the number of fetuses, 
amniotic/chorionic sacs, survey of intracranial, spinal, and abdominal anatomy, evaluation of a  four-chamber heart view, assessment of the umbilical cord insertion site, assessment of amniotic 
fluid volume, and evaluation of maternal adnexa when visible when appropriate. Wax and 
colleagues note that complete evaluation of the fetus for fetal anatomic or genetic abnormality may 
be indicated in twin pregnancy with fetal loss and retention of one fetus, antepartum condition, or 
complication. In this case, the ultrasound and reading of the ultrasound on 8/2/22 was standard 
therapy. Therefore, ultrasound and reading of the ultrasound on 8/2/22 was likely to have been 
more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 30-year-old male enrollee has requested reimbursement for immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19. 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 there is sufficient support for the services at issue in this clinical setting. This patient did not have a diagnosis, and an underlying lymphoproliferative disorder was suspected. T-cell lymphomas are a subtype of non-Hodgkin lymphomas that can present with leukopenia, pruritus, skin infiltration, organomegaly, eosinophilia, thrombocytopenia, and anemia. T-cell receptor rearrangement is part of routine testing in such cases. The presence of TCR clonality raises the suspicion of lymphoma but a negative result does not rule it out. Thus, the order of T-cell gene rearrangement was indicated to rule out a clonal T-cell receptor disorder. Similarly, most non-Hodgkin lymphomas are derived from B-cells where immunoglobulin heavy and light chain rearrangement studies are standard diagnostic procedures. The current National Comprehensive Cancer Network guidelines for lymphomas, both B-cell and T-cell, state that gene rearrangement studies are part of the diagnostic algorithm. Gene rearrangement studies are the standard of care. All gene studies ordered in this case were part of standard medical care. Thus, immunoglobulin heavy chain locus gene rearrangement and immunoglobulin kappa light chain locus gene arrangement testing performed on 2/14/19 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that there is a lack of support for the requested device in this patients case. The records do not document a nonsteroidal anti-inflammatory drug trial. There is no surgical consultation that addresses the extruded disc in her neck. While there is literature supporting the use of cervical spinal cord stimulator for cervical radiculopathy, there are several available alternatives before embarking on spinal cord stimulation. Therefore, the implanted electrical stimulator is not likely to be more effective than other treatment options. Based upon the information set forth above, the requested device 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 


A 52-year-old male enrollee has requested reimbursement for sleep study (CPT 95810) performed on 7/16/16. The Health Plan has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees possible obstructive sleep apnea.  The physician reviewer found that based on the medical literature and the presented clinical records submitted for review, the sleep study (CPT 95810) performed on 7/16/16 was medically necessary for evaluation of the patients medical condition. In this case the patient was suspected of having obstructive sleep apnea due to reports of snoring and daytime sleepiness. The sleep study performed is in accordance with the current standards of practice by the American Academy of Sleep Medicine (AASM). It is also generally accepted that a sleep technologist is not to initiate a split-night study unless the laboratory criteria for the performance of a split-night study is met which prevents the initiation of continuous passive airway pressure (CPAP) for patients who do not or may not require therapy. A technologist is then to run the study as a diagnostic sleep test (Robertson, et al). The patients sleep study did not demonstrate that the patient had a frequency of respiratory events in the early part of the study that would have met the threshold for initiation of a split-night study. The study was continued as a diagnostic polysomnography. Thus, the use of split-night study was not clinically appropriate. All told, the service at issue has been established as medically necessary for evaluation of the patients medical condition. 
Therefore, the service at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 52-year-old male insured has requested authorization and coverage for Panzyga (immune globulin 
(Human)-ifas). The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insureds small fiber neuropathy and paresthesia of 
the feet. The physician reviewer found that the records reflect that this patient has a history of small 
fiber neuropathy with symptoms including progressive paresthesia in his lower extremities and feet. 
Antibody testing was obtained, and the patient tested positive for TS-HDS. Per the provider, the patient 
has tried and failed medications such as Effexor, Elavil, Lyrica, Cymbalta, gabapentin, meloxicam, 
mexiletine, and topical lidocaine. These medications are considered first-line or standard therapies for 
patients with small fiber neuropathy. The current medical literature has shown that IVIG is beneficial for 
patients with small fiber neuropathy who test positive for the TS-HDS antibody (Zeidman and Kubicki). 
While there is a lack of direct comparative studies analyzing the efficacy of IVIG versus standard 
therapies for the treatment of patients with small fiber neuropathy, Panzyga is an established next step 
in therapy that has shown to be efficacious for such patients. Additionally, the records reflect that this 
patient has previously tried and received benefit from IVIG. For these reasons, the requested Panzyga 
(immune globulin (Human)-ifas) is likely to be more beneficial for the treatment of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 53-year-old male enrollee has requested reimbursement for the bronchial thermoplasty provided from 1/21/15 through 4/8/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found the U.S. Food and Drug Administration (FDA) approved the procedure in 2010 as safe and effective for use in patients with poorly controlled asthma who fail to improve despite treatment with maximal medical therapy. Poorly controlled asthma affects a patients life in many ways. The fact that this patient requires multiple steroid bursts means that he is at increased risk for steroid side effects. Thus, due to the severity of the condition in this patient, that bronchial thermoplasty has the potential to lead to improved asthma control, decreased use of prednisone, perhaps the elimination of Xolair, and allergy shots. Since this procedure is only indicated for patients with severe asthma who are steroid dependent, as this patient, the bronchial thermoplasty services provided from 1/21/15 through 4/8/15 were 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 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: Upheld

Summary Reviewer 


A 59-year-old female enrollee has requested reimbursement for the OncotypeDX assay provided on 3/31/16. The Health Insurer has denied this request indicating that the testing at issue was not medically necessary for evaluation of the enrollees high grade ductal carcinoma in situ (DCIS).The physician reviewer found that a lumpectomy for DCIS, the standard of care is radiation therapy to the remaining breast (Goodwin, et al). However, there is controversy as to whether every patient should receive radiation, or whether it can be individualized. Many efforts have been made to determine just who should receive radiation and who does not need it (Silverstein and Lagois). However, it does not give real information about the impact of radiation therapy on those with a high risk, such that it has not become standard of practice. Furthermore, this patient had several features that would have meant a recommendation for radiation therapy, even without the assay results. Thus, the OncotypeDX assay provided on 3/31/16 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the testing at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 71-year-old male enrollee has requested reimbursement ablation of the prostate, transrectal high intensity focused ultrasound (HIFU) including imaging guidance performed on 12/20/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who has a history of prostate cancer. The physician reviewer found that the patient is a 71-year-old male with a recurrence of prostate cancer with T2c predominantly Gleason 7 (4+3) cancer. The patient has requested reimbursement for the ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17. The Health Insurer has denied this request on the basis that the services at issue were considered investigational for treating this patients medical condition.There are some studies to support the efficacy of HIFU for early recurrence of prostate cancer when prostate specific antigen is less than 4 and a focal recurrent site is evident and low Gleason score is predominant. However, in this patients case, he has a recurrence of prostate cancer with a Gleason score of 7. In this case, use of HIFU was not likely to have been superior to other available techniques. While there is emerging data for its use in some patients, the current data has not shown its superiority over other salvage techniques. Therefore, the ablation of the prostate using transrectal HIFU including imaging guidance performed on 12/20/17 was not likely to have been superior over the available treatment options for this patient.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 1

A 63-year-old female has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pain. The physician reviewer found that this patient presented with persistent and worsening low back pain radiating into the bilateral lower extremities, and severe sacroiliac joint pain. She was status post anterior and posterior lumbar fusion from L3 through the sacrum. She had recently been involved in a motor vehicle accident with elevation of symptoms. There is imaging evidence of facet and disc pathology at the adjacent L2-3 level. Surgery has been requested to include L2-3 decompression and interbody fusion with fusion from L2 to the pelvis, including the sacroiliac joints. Inclusion of the sacroiliac joints into the surgical construct would typically be supported upon documentation of pain generation relative to the sacroiliac joints. However, there is no documentation of physical examination indicators of pain relative to sacroiliac joint pathology, including three positive provocative tests. There is no documentation of radiographic evidence of spondyloarthropathy. There is no documentation of at least 75% pain reduction following a diagnostic intraarticular sacroiliac joint injection. Therefore, the requested sacroiliac joint fusion is not likely to be of greater benefit than other available 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: Medical Necessity
Decision: Upheld

Summary Reviewer 3

A 64-year-old male enrollee has requested reimbursement for the LifeVest provided from 3/31/17 forward. The Health Insurer has denied this request indicating that the device at issue was and is considered investigational for treatment of the enrollees myocardial infarction and congestive heart failure.   The physician reviewer found this patient presented with an acute anterior myocardial infarction and underwent emergent revascularization with LAD and PCI. He had recurrent chest discomfort and repeat angiogram revealed stent thrombosis of both vessels. The LAD was reopened and post procedural echocardiogram revealed a severely depressed EF at 24%. He does not have an initial indication for an implantable defibrillator since he was less than 40 days since his myocardial infarction and also less than 90 days from PCI revascularization (Chung, et al). His EF may be transiently low and may improve over time due to recovery of stunned myocardium from the myocardial infarction. Thus, a wearable LifeVest cardioverter defibrillator can provide temporary protection from early sudden death due to arrhythmia in this patient population during this interim period. Although no randomized controlled prospective trials have been completed yet, this short-term indication for the wearable defibrillator therapy has support from large published case series literature, a recently published longer term prospective registry, along with expert opinion and an advisory from the American Heart Association (Adler, et al; Klein, et al; Piccini, et al). In this particular clinical situation, the patient has a severely depressed EF and needs aggressive ongoing medical treatment of his congestive heart failure and a 90 day waiting period before he can be re-evaluated for permanent automatic implantable cardioverter defibrillator therapy. For these reasons, the LifeVest provided from 3/31/17 forward was and 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, the device at issue was and 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 23-year-old male enrollee has requested authorization and coverage for powered robotic lower body exoskeleton system. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrolleeas medical condition. The physician reviewer found that there is a lack of support for the requested device in this clinical setting. Knezevic and colleagues stated that exoskeleton assisted walking training improved oxygen uptake efficiency and walking velocities with a lower perception of exertion. However, there was no comparison with other forms of exercise that did not require the use of exoskeletons. Additionally, there was no demonstration of improved health outcomes. Van Dijsseldonk and colleagues stated that participants with complete spinal cord injury reported satisfaction with the exoskeleton for exercise and social interaction in the home and community, but report limitations as an assistive device during daily life. Additionally, there was no comparison with other forms of exercise that did not require the use of exoskeletons. Hong and colleagues identified that the training was safe, feasible, and effective. Most participants improve their walking velocity and distances with the progression of sessions. However, there was no identification of improvement of function or improved health outcomes as a result of this intervention. Many of the studies provided for review had extremely small sample sizes, significant conflicts of interest, no control/comparison group, were focused primarily on exoskeletons during the rehabilitation phase, or did not identify long-term sustained improvement in function or health outcomes as a result of home/community use of an exoskeleton device. Therefore, the requested powered robotic lower body exoskeleton system is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 42-year-old female enrollee has requested reimbursement for supraorbital, occipital and suprascapular nerve blocks of the occipital nerve performed on 10/3/16 and 10/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees chronic headache. 
 The physician reviewer found that there is sufficient support in the medical literature for the services at issue in this clinical setting. Occipital nerve blocks are an established treatment method for the management of chronic headache and chronic migraine. Peer reviewed medical literature has documented its efficacy over placebo controlled blinded studies. This patient has well documented chronic migraine and has failed numerous treatment modalities but was responsive to occipital nerve blocks. As such, the supraorbital, occipital, and suprascapular nerve blocks of the occipital nerve on 10/3/16 and 10/20/16 were likely to have been more effective than the other options for treating this patients medical condition. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 63-year-old male with a history of oligometastatic castration sensitive prostate cancer, with disease extension to a pelvic lymph node, L1, and left ischium. The physician reviewer found that IMRT is standard of care and medically necessary in this clinical setting. Parker and colleagues discussed radiation therapy to the prostate and noted, aOverall survival did improve in men with a low metastatic burden. Therefore, prostate radiotherapy should be a standard treatment option for men with a low metastatic burden.a IMRT is frequently utilized for similar patients in the radiation oncology community. IMRT allows for optimal target coverage while minimizing exposure to the patientas bowel and bladder. The medical evidence supports the requested services in this patientas case. Therefore, the requested radiation therapy (IMRT) is medically necessary for the treatment of this patient.