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

Summary Reviewer 1


A 26-year-old male enrollee has requested authorization and coverage for the LINX reflux management system. 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 according to peer-reviewed published literature, there is only one lower esophageal sphincter (LES) augmentation device designed for the treatment of GERD at this time.  The LINX device has been approved for patients diagnosed with GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. Two post-approval studies are designed to evaluate the long-term effectiveness of the device and incidence of adverse events; however, comparative studies with other anti-reflux surgeries are still needed. While there is some medical literature in support of the use of the LINX device for patients with GERD, appropriate patient selection is crucial before anti-reflux procedures. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach. In this patients case, the records reflect that he has undergone much of this pre-operative assessment and that he has GERD based on pH recording. However, neither his radiographic studies in 2011 nor 2015 evidenced gastroesophageal reflux. As such, he cannot be considered medically refractory given the intermittency of documented reflux. Also, implantation of LINX in this clinical setting must be approached with caution given the patients charted complaint of dysphagia.  As such, 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 62-year-old male who presented to his provider on 1/26/22 with cough for the 
past three weeks. The patient has requested reimbursement for a CT scan without contrast 
performed on 2/10/22. The physician reviewer found that at issue is whether the CT scan without 
contrast performed on 2/10/22 was medically necessary for the evaluation of this patient. The 
submitted documentation supports the medical necessity of the service at issue. The American 
College of Radiology (ACR) appropriateness criteria for the evaluation of chronic cough notes that 
for the evaluation of persistent symptoms of chronic cough, radiography and CT of the chest with 
or without contrast is usually appropriate. In this case, a CT scan, with or without contrast, would 
be an appropriate study in this clinical setting. Therefore, the CT scan without contrast performed 
on 2/10/22 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

I have determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Insurers denial should be upheld. The physician reviewer found that the patient is a 53-year-old male with a history of low back pain. He received mechanized spinal distraction therapy for his low back pain. On 4/25/18, the patient reported that a zero gravity chair helps. The patient took gabapentin at night, and Kenalog injections reportedly provided temporary relief.  Significant objective findings included no ataxia and no shuffling gait, intact cranial nerves, and 2+ reflexes in the upper and lower extremities. Based on the letter dated 7/19/18, the patient reported that he has tried acupuncture and physical therapy. He has requested reimbursement for mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of this patient.

Research does not show that lumbar traction is likely more beneficial for the patients condition compared to any available standard therapy. Schimmel and colleagues found that there was no difference between the Intervertebral Differential Dynamics Therapy and sham therapy 14 weeks after the start of the treatment neither for primary outcome nor for the secondary outcome. Both groups reported a significant improvement in low back pain, leg pain, and daily function. Thackeray and colleagues showed that patients with lumbar nerve root compression presenting for physical therapy can expect significant changes in disability and pain over 6-week treatment period and there is no evidence that mechanical lumbar traction in combination with an extension-oriented treatment is superior to extension-oriented exercises alone in the management of these patients. In sum, mechanized spinal distraction therapy for low back pain provided on 4/26/18, 4/30/18, 5/01/18, 5/02/18, 5/03/18, 5/07/18, 5/08/18, 5/09/18, 5/10/18, 5/14/18, 5/15/18, 5/16/18, 5/17/18, 5/21/18, 5/22/18, 5/23/18, 5/24/18, 5/29/18, 5/30/18 and 6/04/18 was not likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 52-year-old female with a history of chronic low back pain status post Coflex spacer at L4-5.  The patient has requested reimbursement for total disc arthroplasty performed on 7/31/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. As noted by Fornica and colleagues, the two main surgical treatments for lumbar degenerative disc disease are lumbar fusion and total disc arthroplasty. Lumbar fusion relieves pain by fusing vertebrae together, but may result in incomplete pain relief, reduced range of motion, and increased risk of adjacent segment degeneration with recurrent pain. The lumbar total disc replacement avoids these complications by replacing the degenerated disc with a moveable prosthesis, thus relieving pain, preserving motion, and avoiding adjacent segment degeneration. The implants and the procedure have been refined over the years, and good results have been documented. Therefore, the total disc arthroplasty performed on 7/31/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 56-year-old female enrollee has requested authorization and coverage for Botox injection. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Cervical dystonia is an involuntary movement disorder characterized by uncontrolled muscle contraction, often with pain, altered range of motion, and altered head position. This condition can result in headache and neck pain. Spasmodic torticollis is synonymous with cervical dystonia. It is typically idiopathic, but in some cases results from injury. In this patients case, the records noted neck pain, headache of non-migraine character, and limited neck range of motion. Her presentation is consistent with cervical dystonia. The U.S. Food and Drug Administration has approved the use of Botox injections in this clinical setting. Botulinum toxin injections are medically appropriate for the treatment of this patient. Therefore, the requested Botox injection is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The parent of a 15-year-old male enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the patient is a 15-year-old male with fistulizing Crohns disease with perianal involvement.  On 10/27/15, colonoscopy revealed granulomas in the colon and terminal ileum.  Remicade therapy was recommended and induced at 5.5 mg/kg.  Laboratory work on 2/05/16 with the patients second Remicade infusion showed normal comprehensive metabolic panel, normal C-reactive protein, and normal sedimentation rate.  The patients parent has requested reimbursement for Prometheus Anser IFX testing performed on 5/13/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient. The Prometheus Anser IFX test is a quantitative measurement of serum infliximab and anti-infliximab antibodies.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results.  Limited retrospective evidence describes changes in management after measurement of anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has yet to be established whether the use of threshold infliximab levels aid in the discrimination of treatment response, nor the optimal timing of when to measure antibody levels.  Therefore, Prometheus Anser IFX testing performed on 5/13/16 was not likely to have been more effective than other options for evaluating this patient.  Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 57-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing provided on 8/30/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas melanoma. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Thus, DecisionDx-Melanoma testing provided on 8/30/19 was not likely to have been more beneficial than other methods of evaluating this patient
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for Vascepa 1 gm capsule. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the patient has a low, ten-year risk of cardiovascular disease at approximately 2%. He does have high triglyceride levels, which may require treatment, but a baseline low LDL cholesterol level. He does not have diabetes or known cardiovascular disease. He is not on statin therapy, as his LDL is low and he is not in a high cardiovascular risk group. Vascepa therapy has been approved and is indicated for use in patients with known cardiovascular disease or diabetes and two other cardiovascular risk factors as adjunctive therapy to high dose statin in these specific patients. It has not been shown yet to be indicated as monotherapy to lower isolated hypertriglyceridemia in low cardiovascular risk individuals unless other therapies (fibrates, Lovaza) have failed or are not tolerated. Although Lovaza has been implicated in possibly raising LDL levels in at-risk individuals, this patients LDL is already quite low at baseline. Although the patient may require therapy to lower his triglycerides, lifestyle modifications along with generic Lovaza or fibrate therapy would be reasonable first-line alternatives to lower triglyceride levels in the absence of established coronary artery disease or diabetes and additional multiple high-risk features for cardiovascular disease. Therefore, Vascepa 1 gm capsule is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 42-year-old female enrollee has requested authorization and coverage for destruction of intraosseous basivertebral nerve. 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 guideline published by International Society for the Advancement of Spine Surgery concluded that the intraosseous basivertebral nerve ablation for the treatment of chronic low back pain is a treatment option that has supporting level 1 evidence for patients with clinical and radiologic findings supporting a vertebrogenic source of back pain. The procedure has two randomized controlled trials that showed statistically significant pain scores and also functional improvements over a two-year period. This patientas clinical and radiologic findings of Modic type 1 changes at L4-5 support a vertebrogenic cause of back pain. She has not had any relief from comprehensive and multimodal treatment options and has exhausted these therapies. Chronic use of opioids is not indicated for the treatment of chronic low back pain. Radiofrequency ablation of the basivertebral nerve is the appropriate next step in the treatment algorithm and is likely to provide functional relief to the patient. Therefore, destruction of intraosseous basivertebral nerve is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
A  52-year-old  female  enrollee  has  requested  authorization  and  coverage  for  the  Intracept 
procedure. The Health Insurer has denied this request and reported that the requested medication 
is investigational for the treatment of the enrollees low back pain. The Health Insurer indicated 
that the requested service is investigational for the treatment of the enrollees medical condition. 
Therefore, the Health Insurer has denied coverage for the requested service. The physician reviewer 
found that the patient has chronic low back pain. While the provider noted in a letter dated 12/8/22 
that there are Modic changes on MRI, the submitted MRI report dated 7/1/22 specifically states 
that the bone marrow signal in the vertebral bodies is normal. Fischgrund and colleagues along 
with  Truumees  and  colleagues  note  that  the  requested  procedure  is  more  effective  than 
conservative care in the setting of bone marrow changes associated with degenerative disc disease.  
However, in this clinical setting, given the lack of Modic endplate changes noted on the patients 
MRI report, the requested service is not likely to be more beneficial than standard, conservative 
care. Therefore, the Intracept procedure is not likely to be more beneficial for treatment of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 36-year-old female with dysmenorrhea which was interfering with her quality of life. She opted for an endometrial ablation for treatment.  The patient tried oral contraceptive pills. However, she failed this treatment due to headaches. The patient is a smoker, and her partner has had a vasectomy. On 12/30/16, endometrial ablation was performed. The Health Insurer has denied reimbursement for the services at issue. Per the Health Insurer, endometrial ablation was investigational for the treatment of this patient. There is sufficient support for the services at issue in this clinical setting. Endometrial ablation is an effective, minimally invasive treatment for heavy menstrual bleeding. There are several techniques available, and all techniques have been shown to reduce menstrual bleeding by a statistically significant amount. This is a useful treatment for avoiding hysterectomy and was an appropriate choice for this patient. Thus, endometrial ablation performed on 12/30/16 was likely to have been of greater benefit than other available treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the services at issue in this patients case.  This patient has osteoporosis and has had multiple fractures.  She has been treated with Forteo and Prolia was subsequently prescribed.  Since she had fractures on Fosamax, there is sufficient support for the Prolia.  In sum, the Prolia injection provided on 8/27/15 was likely to have been of greater benefit than other treatment options.  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 

A 31-year-old female enrollee has requested authorization and coverage for Forteo. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that thesubmitted documentation supports the medical necessity of the requested medication. Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. In humans, the elimination half-life of bisphosphonates is over 10 years. This raises concerns that in women of childbearing age, alendronate stored in the bone may be mobilized during pregnancy and taken up by fetal bones and may be potentially teratogenic. Newer treatment agents have become available over the past few years, including teriparatide (Forteo). Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. The pharmacokinetics of Forteo have been characterized by rapid absorption and rapid elimination, resulting in a short total duration of exposure to the peptide. Therefore, Forteo (teriparatide) is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 51-year-old female enrollee has requested authorization and coverage for endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who is diagnosed with venous insufficiency. The physician reviewer found that there is sufficient support in the documentation provided for the requested services in this clinical setting. An examination dated 2/22/17 noted multiple areas of bulky varicose veins in the area of the right medial thighs, particularly directly above the knee. In an undated letter, the treating provider reported that ultrasounds confirmed fairly significant venous insufficiency and recommended venous ablation. Based on the documentation submitted, this patient is likely to be well served by ablation, and she meets standard criteria for treatment of her venous insufficiency that is refractory to compression stockings. Additionally, the medical literature supports the efficacy of this therapy for treatment of the patients medical condition. Her treating provider has assessed her vein as an appropriate target for ablation. In sum, endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency is medically necessary for treatment of this patients medical condition.
Therefore, for the reasons stated above, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.