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

Summary Reviewer 1


A 37-year-old male enrollee has requested authorization and coverage for placing devices in neck (insertion of more than one artificial intervertebral disc).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition.  The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has left upper extremity symptoms and subtle findings of a cervical radiculopathy (Polston) with mild left triceps weakness and no atrophy/loss of sensation, nor reflex changes. In addition, two level artificial disc replacement remains controversial. The study by Davis and colleagues is a promising study but lacks long term safety and effectiveness data to make conclusions. There is a lack of randomized, prospective, scientific studies that have shown the long term safety and effectiveness of the proposed procedure. All told, the requested neck surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the medical literature recommends using a pain diary to verify when the local anesthetic wore off for the treatment of diagnostic medial branch block prior to radiofrequency ablation (Derby, et al). According to the documentation available for review, the records do not document a pain diary. Moreover, it is unclear that she obtained significant benefit from the prior radiofrequency ablation. The record submitted does not support that she did obtain relief to corroborate improvement, with no mention of increased functional benefit from a baseline or decrease in perceived pain from a baseline. Therefore, the request for radiofrequency neurolysis 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 service 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 33-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that based on the available documentation, the services provided from 6/11/17 through 7/2/17 were medically necessary for treatment of this patients schizoaffective disorder and stimulant use disorder. The RTC services could not have been adequately and effectively delivered in a less restrictive setting. The patients debilitating formal thought disorder fueled impairment in all functional domains. He was treated with a relatively high dose of clozapine, which is a complex antipsychotic typically reserved for the most refractory of cases. In addition to his psychosis, the patient had co-occurring depression, anxiety, addictive illness and thyroid disease and history of multiple psychiatric hospitalizations including prior admissions during the episode of illness. On 6/11/17, the patient was mildly anxious and labile. His insight and judgment were both impaired. He reported suicidal ideation and auditory hallucinations. He had recently relapsed on methamphetamine. Given these reports, the patient had not yet consolidated the treatment gains necessary to succeed in the outpatient setting. However, the patient remained engaged in active treatment. He was described by staff as depressed, lethargic, flat, constricted and distracted. He had frequent auditory hallucinations. He had thought blocking on 6/29/17. Further, he was experiencing sedation with the increasing doses of clozapine and amitriptyline. During the disputed timeframe, the residential setting was reasonably expected to improve the patients condition and prevent a more serious episode of illness. The duration of services was consistent with community standards for a case of this complexity. Considering the chronicity and severity of the disease burden, the RTC services provided from 6/11/17 through 7/2/17 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: Experimental
Decision: Overturned

Summary Reviewer 1

A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that this patient is an adult with morbid obesity and a BMI of 48.9 kg/m2. The medical literature indicates that the duodenal switch (DS) is associated with significantly more risk of micronutrient and protein malnutrition. In this patients case, there are no recent dietary or psychological evaluations provided for review. Separately, there is additional risk involved and a separate psychological evaluation needs to be performed to ensure that this patient has the appropriate current level of understanding and an appropriate candidate for reoperative bariatric surgery. There is no complication of the prior sleeve gastrectomy that requires surgical treatment. There is also no record of a comprehensive updated multidisciplinary evaluation. Additionally, the record does not indicate that the additional micronutrient risks have adequately been addressed at this time. As such, biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are not likely to be superior over the standard methods for the treatment of this patient.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 

A 42-year-old female enrollee has requested authorization and coverage for substance use inpatient detoxification provided from 10/03/18 through 10/08/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to the patients presentation to help determine the appropriate level of care. The patient did not meet the criteria for dimension 1) acute intoxication and/or withdrawal potential. Additionally, the patient did not meet the criteria for dimension 2) biomedical condition and complications. According to the ASAM criteria, all six dimensions must be met for placement in this level of care. Therefore, substance use inpatient detoxification from 10/03/18 through 10/08/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 61-year-old female enrollee has requested coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees left hip and buttock pain. The physician reviewer found that the North American Spine Societys recommendations include that percutaneous sacroiliac joint fusion should only be considered when all inclusion criteria have been met. The authors state that due to the relatively moderate evidence, it is particularly critical that inclusion criteria are scrutinized and patient selection is executed with vigilance. In this case the patient meets North American Spine Society criteria for the proposed sacroiliac joint fusion. She has had at least 75 percent reduction of pain for the expected duration of the anesthetic used following an image-guided, contrast-enhanced intra-articular SIJ injection on two separate occasions. In addition, the postoperative CT scan on 11/5/15 shows no ongoing neural compression and no central canal or foraminal stenosis on the postoperative CT scan. This patient meets all NASS criteria for the proposed surgery. For these reasons, sacroiliac joint fusion surgery 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 requested services 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 45-year-old female enrollee has requested authorization and coverage for transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484). The Health Insurer has denied this request indicating that the requested service is not medically necessary for treatment of the enrollees chronic low back pain.  The physician reviewer found that based on the presented clinical records submitted for review, transforaminal epidural injection of the lumbar or sacral (CPT codes 64483 and 64484) is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting the requested service in this clinical setting. Manchikanti and colleagues show good evidence with the use of transforaminal epidural injections in managing disc herniation and radiculitis. According to the documentation submitted for review, a repeat transforaminal epidural steroid injection of the lumbar spine is clinically indicated due to the patients return of pain which was identical to the pain prior to the previous injection. In addition, the provider has documented appropriate patient response to the previous injections with more than 80% pain relief of symptoms and leg pain lasting for over 10 months. After the previous injections the patient did not require pain medications and has had adequate conservative treatment including physical therapy. For the reasons provided, the requested service has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested service 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 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 6/24/16. The Health Plan has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees breast examination. The physician reviewer found that the tomosynthesis often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional (2D) imaging alone. The American College of Radiology (ACR) considers 2D mammography as medically necessary for the screening of breast cancer, and considers the addition of tomosynthesis to be of added value for patients with dense breast tissue. Although breast tomosynthesis has become widely accepted in the breast imaging arena, breast tomosynthesis performed on 6/24/16 is not considered medically necessary for evaluation of the patients medical condition.  Therefore, the service at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 11/16/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance abuse, depression, and post-traumatic stress disorder (PTSD).   The physician reviewer found that the records indicate that this patient had been receiving treatment at the IOP level of care for the three months immediately prior to his admission to RTC. He was transferred because he was not making progress and was considered at high risk for suicide. His history also reveals severe functional impairment. In addition, he had three previous psychiatric hospital admissions prior to the RTC. Thus, he meets the American Society of Addiction Medicine (ASAM) criteria for 24-hour treatment as he was considered a high risk for harm, he had severe social impairment that could not be managed with IOP, and had a history that his providers noted placed him at high risk for destabilization and relapse without RTC level of care. He also needed high levels of motivation from staff to address his lack of treatment engagement. Given these findings, the RTC services provided from 11/16/15 through 12/15/15 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15.  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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  In addition, there had been no change when compared to yearly mammograms dating back eight years.  Thus, breast tomosynthesis performed on 7/10/15 was not likely to have been of greater benefit than other modalities.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 56-year-old female with a history of relapsing multiple sclerosis, type 1 diabetes, and hypothyroidism. The patient has requested authorization and coverage for Acthar (corticotropin injection gel 80 units/mL). The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found standard therapy for acute exacerbations of multiple sclerosis has been high-dose corticosteroid therapy.  Adrenocorticotropic hormone (H.P. Acthar gel) has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of exacerbations of multiple sclerosis in adults.  Other therapies include plasmapheresis and intravenous immunoglobulin (IVIG). Plasmapheresis is generally reserved for treatment of relapses that are severe or refractory to treatment with high-dose corticosteroids. IVIG is sometimes used in patients for whom high-dose corticosteroids are contraindicated or not tolerated, but there is a lack of consistent evidence for its use in relapse management. Per Ross and colleagues, adrenocorticotropic hormone gel may be considered as an alternative treatment of multiple sclerosis relapses and is generally used as an alternative to high-dose corticosteroids. The authors noted, that the reasons for using adrenocorticotropic hormone include a lack of benefit established with corticosteroids, inability to tolerate corticosteroids or adverse effects, and poor intravenous access. Its efficacy has been studied in several published investigations, and treatment outcomes may be comparable to those seen with corticosteroids. Bell and colleagues performed a randomized, open-label, crossover study that evaluated 18 patients with multiple sclerosis treated with subcutaneous H.P. Acthar gel and intravenous methylprednisolone. Preliminary results suggest that fewer drug-related adverse effects occurred with Acthar gel than intravenous methylprednisolone for treatment of multiple sclerosis exacerbations. Kutz performed a retrospective review of patients with multiple sclerosis exacerbations and diabetes treated with Acthar gel. The data suggested that Acthar gel may be a well-tolerated and effective treatment option for patients with diabetes experiencing a multiple sclerosis relapse. In this case, the patient has multiple sclerosis with uncontrolled exacerbations and has failed conventional therapy with high-dose corticosteroid therapy. She also has diabetes and developed uncontrolled blood sugars with corticosteroid treatment. She seeks approval for Acthar gel for treatment of acute exacerbations. Acthar gel is an FDA approved therapy for multiple sclerosis exacerbations and is used for patients who fail corticosteroids and patient who are unable to tolerate corticosteroids or their side effects, both of which apply in this case. Therefore, Acthar (corticotropin injection gel 80 units/mL) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 43-year-old female who has a history of right sided low back. She reported increasing low back pain over the past several years. The patient has requested authorization and coverage for sacroiliac joint fusion.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patients low back pain. There is a lack of long term studies that demonstrate the superior efficacy of the requested procedure in this clinical setting. The effectiveness of sacroiliac joint fusion when compared to standard treatment protocols remains unconvincing as a treatment modality for patients who are diagnosed with low back pain. In this patients case, the documentation does not support evidence of sacroiliac joint instability, fracture, or lesion. A magnetic resonance imaging was noted as showing degenerative disc disease but no lesions were found. The diagnostic imaging does not confirm a medical condition that would provide an indication for sacroiliac joint fusion. Thus, the medical evidence does not support the efficacy of the requested procedure in this patients case. As such, sacroiliac joint fusion is not likely to be of greater benefit for treating this patients medical condition than the available standard treatment methods. Therefore, 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: Experimental
Decision: Overturned

Summary Reviewer 2


A 60-year-old female enrollee has requested reimbursement for Prolia (denosumab) injection administered on 10/20/15. The Health Insurer has denied this request indicating that the medication at issue is considered investigational for treatment of the enrollees osteoporosis. The physician reviewer found upon review of the medical record, Prolia was likely to be more efficacious in treating the patients medical condition than any available standard therapy. A substantial amount of medical evidence exists to support Prolia as an appropriate treatment option for patients with osteoporosis. Furthermore, Prolia has received Food and Drug Administration approval for the treatment of osteoporosis. The patient has documented osteoporosis with a history of fracture. The DEXA scan of the patients hip and spine demonstrate treatment with Prolia.  In sum, the second injection of Prolia in October 2015 was beneficial for treatment of this patients osteoporosis.Based upon the information set forth above, the medication at issue was 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 3

A 63-year-old female enrollee has requested reimbursement for advanced lipoprotein testing performed on 10/19/20. 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 there is support for a portion of the services at issue. The National Lipid Association stated that lipoprotein (a) testing is reasonable to refine atherosclerotic cardiovascular disease risk in adults with the following: first-degree relatives with premature atherosclerotic cardiovascular disease risk (less than 55 years of age in men; less than 65 years of age in women); a personal history of premature atherosclerotic cardiovascular disease; primary severe hypercholesterolemia (LDL greater than or equal to 190 mg/dL) or suspected familial hypercholesterolemia. This patient does appear to meet the first of these criteria for lipoprotein (a) measurement. Thus, CPT 83695 was likely to have been more beneficial than other available standard methods of evaluating this patient. Apolipoprotein B may be a useful risk assessment tool in patients with normal LDL who have a high family risk for premature coronary artery disease. However, apolipoprotein B assays have not been fully standardized, and there is a lack of consensus on predictive or treatment value. Rosenson suggests the measurement of LDL particle concentration, or the surrogate measure of apolipoprotein B, in individuals with insulin resistance disorders who have not achieved their minimal acceptable LDL cholesterol targets. This patient does not meet these criteria for lipoprotein B measurement. Therefore, CPT codes 82172 and 83704 were not likely to have been more beneficial than other available standard methods of evaluating this patient.