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

Summary Reviewer 


A 49-year-old male enrollee has requested reimbursement for the chiropractic services (CPT codes 98941, 98943, 97110, and 97012) provided on 12/14/16, 4/21/17, 5/17/17, 6/9/17, and 7/6/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees neck and shoulder pain. The physician reviewer found that the patient has a chronic condition and has received extensive chiropractic care. However, there is no clear objective documentation on functional improvement or specific goals with chiropractic treatment. The records suggest that the treatments have been provided as supportive care. Chiropractic maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong or enhance the quality of life, or therapy is that is performed to maintain or prevent deterioration of a chronic condition. As noted by the Centers for Medicare and Medicaid Services (CMS), when further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is considered maintenance therapy and not considered medically necessary. Therefore, the chiropractic treatments with ancillary treatments provided on 12/14/16, 4/21/17, 5/17/17, 6/9/17, and 7/6/17 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 1

A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. This particular melanoma could not be accurately staged, as the thickness could not be determined due to the fact that the tumor had apparently regressed spontaneously prior to biopsy. The features that could be seen included that there was no ulceration and no mitoses. DecisionDx-Melanoma testing is a study of 31 genes in a particular melanoma. It then classifies that melanoma into either Class 1 or 2, with a significant difference in the risk of recurrence at five years between these two classes. Gerami reported on 217 cases, with good correlation in prognosis between the two DecisionDx-Melanoma testing classes in patients who have undergone sentinel node biopsy. Berger and colleagues reported on 156 patients, but the follow-up was not sufficient to determine the real value of the test. It is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it has not been shown that DecisionDx-Melanoma testing can be used to make clinical decisions about treatment. Therefore, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 55-year-old female with a history of hyperlipidemia. Per the medical records, she is intolerant to multiple statin medications. The submitted documentation noted coronary artery disease including prior coronary artery revascularization. On 12/14/17, low-density lipoprotein (LDL) level was 182 mg/dL. The patient has requested coverage for Praluent injection 75 mg/ml subcutaneous solution. 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 submitted documentation supports the medical necessity of the requested medication. This patient has known obstructive coronary disease and marked hyperlipidemia. She is intolerant of several statin medications. Praluent is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter category. There is documented intolerance to several statin medications, and the use of ezetimibe alone would not be expected to achieve an LDL reduction to less than 70 mg/dL, the current goal in patients with documented obstructive coronary disease, such as this patient. PCSK9 inhibitors such as Praluent have been documented in several randomized controlled trials to be safe and effective at lowering LDL cholesterol and associated with improved outcomes. Thus, Praluent injection 75 mg/ml subcutaneous solution is medically necessary for the treatment of this patient. Therefore, the requested medication is 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 24-year-old female enrollee has requested authorization and coverage for lower esophageal 
myotomy, transoral (peroral endoscopic myotomy) (POEM) and one inpatient day. The Health 
Plan has denied this request indicating that the requested service is investigational for the 
treatment of the enrollees medical condition. The physician reviewer found that this patient has 
a longstanding history of achalasia and has had symptoms of dysphagia, regurgitation and weight 
loss.  She has undergone various tests including, esophageal manometry, and pH testing, which 
are collectively suggestive of a diagnosis of achalasia. Her symptoms have been refractory to 
therapy with esophageal dilatation. The provider has recommended the POEM procedure.  In 
reviewing the literature, there is a lack of well-designed randomized controlled trials that have 
proven the safety and efficacy of the requested therapy. Therefore, lower esophageal myotomy, 
transoral POEM and one inpatient day is not likely to be more beneficial than any available 
standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 58-year-old female enrollee has requested authorization and coverage for the LINX device.  The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD) and esophagitis. The physician reviewer found that the LINX device received U.S. Food and Drug Administration (FDA) premarketing approval in March 2012. The approved indication was for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medical therapy for the treatment of reflux. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative work-up for antireflux surgery (Jobe, et al). This patient has undergone much of this pre-operative assessment. Although this patient has GERD as based on pH recording and Barretts histology, the available records do not demonstrate that she is medically refractory to acid blocker drugs. Also, implantation of LINX in this patients setting must be approached with caution given her documented esophageal dysmotility and functional outlet obstruction and because LINX has not been adequately evaluated in patients with Barretts esophagus. As such, the requested LINX device is not likely to be more beneficial than available standard therapy for treatment of this patients medical condition. 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: Upheld

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for polymerase chain reaction (PCR) testing provided on 5/30/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of enlarged lymph nodes. The physician reviewer found that the Epstein-Barr virus is the main etiology of infectious mononucleosis (IM) syndrome that is characterized by fever, sore throat, and lymph adenopathy. Since this virus could be associated with a number of malignancies, some hematologic disorders, and chronic fatigue syndrome, identification of IM is of importance.  The majority of the human adult population is infected with EBV. Usually the infection is well tolerated without any further symptoms after primary infection. In some patients with infectious mononucleosis, or in some who had an infection in their past, it may be important to diagnose symptomatic disease or differentiate infectious mononucleosis from other conditions. In these cases, serological methods, i.e., immunofluorescence, ELISA, or Western blot, are the methods of choice to come to an unequivocal diagnostic conclusion, while the detection and quantification of viral DNA through PCR plays a minor role. ELISA could be applied as a first and preliminary diagnostic test for IM. In addition, this test could be applied in various phases of the disease with a higher sensitivity comparing to PCR. In individuals where EBV infection is associated or causally linked with autoimmune or malignant disease or in patients who have been bone marrow or solid organ transplanted, or in patients with severe immune-suppression, prolonged EBV primary infection or EBV reactivation from latency may be a serious and life-threatening complication. As such, determining the serostatus correctly is important for these patients. However, in this patients case, there was no documentation that this patient had immunosuppression or that she was a transplant patient. In sum, for this patient who presented with lymphadenopathy of unknown origin, PCR testing provided on 5/30/17, was not likely to have been superior over other standard methods of evaluating her medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 40-year-old female enrollee has requested reimbursement for fetal sex chromosome analysis, circulating cell-free fetal DMA in the maternal blood provided on 6/13/19. 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 screening for the most common sex chromosome aneuploidies is controversial because these individuals have fewer serious physical abnormalities than those with trisomy 21, 18, or 13, and the phenotypic features are much more variable. The American College of Medical Genetics and Genomics (ACMGG) does not recommend use of cell-free DNA to screen for autosomal aneuploidies other than those involving chromosomes 13, 18, and 21. The Harmony Noninvasive Prenatal Testing offers screening for traditional aneuploidies (13, 18 and 21), which is evidence-based and standard of care. However, the test also offers screening for common sex chromosome aneuploidies, which is not recommended by the ACMGG and does not reflect standard of care. Therefore, fetal sex chromosome analysis (CPT 81599) performed on 6/13/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 36-year-old female enrollee has requested reimbursement for gene testing (MaterniT21 Plus) performed on 2/03/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found the current standard of care recommends offering prenatal cell free fetal DNA testing to patients at increased risk.  This population is defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first-trimester or second-trimester screening test results.  Earlier testing increases the chance of a false-negative test due to inadequate amounts of genetic material at earlier gestational ages.  However, cell free testing has not been approved for use in multiple gestations due to limitations on accuracy.  Additionally, this patient underwent cell free fetal DNA testing when she was only seven weeks gestation, which is earlier than recommended.  All told, the superior efficacy of gene testing performed on 2/03/15 has not been established.  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 


A 42-year-old female enrollee has requested reimbursement for mental health inpatient services provided from 5/11/15 through 5/14/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bipolar disorder type 1.  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. Although community intervention settings optimize treatment gains, episodic placement in more restrictive settings is often clinically appropriate for those with serious mental illness. The records indicate that this patient was plagued with the most serious of affective disorders. Bipolar disorder with psychotic features is commonly associated with poor clinical outcomes. When considering the formidable symptom complex, multiple recent hospitalizations, available support system and functional impairment across multiple domains, a conservative inpatient hospitalization was to be expected. During the course of the admission, the patient was hostile, unpredictable and agitated. She had difficulty self-regulating her behaviors and poor insight to her illness. She had refused mood stabilizing medication. On 5/6/15, she was administered psychotropic medication via injection due to her agitation. On 5/11/15, the patient was assessed to lack medical decision making capacity. Thereafter, she was adherent with pharmacotherapy. On 5/12/15, the patients hostility had tempered to irritability while she remained circumstantial, paranoid and grandiose. However, the patient evidenced a positive response to pharmacologic intervention. She was guarded, but better organized and able to participate in discharge planning. Although not suicidal, the patients condition was consistent with grave disability. Based on her illness burden and history of multiple psychiatric admissions in less than one year, the mental health inpatient services provided from 5/11/15 through 5/14/15 were reasonably expected to improve her condition and prevent a more serious episode of illness and thus were medically necessary. 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: Upheld

Summary Reviewer 1

A 36-year-old male enrollee has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request indicating that the device at issue was considered investigational for evaluation of the enrollee, who reported palpitations. The physician reviewer found that the patient is a 36-year-old male with a history of hypertension and diabetes. He reported palpitations. Per the records, the patient underwent a 30-day external event monitor which revealed a symptomatic, but single episode, of atrial fibrillation lasting approximately 30 seconds. He was referred for implantable loop recorder to further assess atrial arrhythmic burden. The patient has requested reimbursement for an implantable ambulatory event monitor provided on 12/28/17. The Health Insurer has denied this request and reported that the device at issue was investigational for the evaluation of this patient. The patient has symptoms of palpitations and would be at higher risk for embolic stroke if he had a significant burden atrial fibrillation associated with these episodes. He would then likely require lifelong anticoagulation. He was first assessed appropriately with an external 30-day event monitor which revealed one episode of symptomatic, although short-lived, atrial fibrillation. A single 30-second episode of atrial fibrillation may not be a definite indication to commit this patient to lifelong anticoagulation, but more sustained or frequent episodes may be an indication for lifelong anticoagulation. In this setting, an implantable recording device is a reasonable next step to assess the full burden of atrial fibrillation prior to starting anticoagulation. Therefore, implantable ambulatory event monitor provided on 12/28/17 was likely to have been more effective than other methods of evaluating this patient. Based upon the information set forth above, the device 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: Upheld

Summary Reviewer 1

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 12/16/18. 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 Polymerase chain reaction testing is appropriate and medically indicated when done to test for chlamydia, gonorrhea, and trichomonas. In this case, it appears the patient was tested for trichomonas (not by polymerase chain reaction testing, but via RNA testing), and was not tested for chlamydia or gonorrhea. Instead, multiple polymerase chain reaction tests were done for various other vaginal organisms, some of which do not even cause infection, including candida species, lactobacillus species, Atopobium vaginae, Megasphaera species, and Gardnerella vaginalis quantification. Polymerase chain reaction testing for these organisms is not standard of care. The standard testing for evaluation of a vaginal discharge includes assessing the symptoms, the appearance of the discharge, pH testing of the vaginal fluid, examination of the discharge under the microscope, and sometimes DNA probes or cultures. Therefore, polymerase chain reaction testing performed on 12/16/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement for the hysterectomy performed on 1/16/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees post-menopausal bleeding. The physician reviewer found that the records provided for review document that this patient presented with a history of post-menopausal bleeding that interfered with her activities of daily living and did not responded to medical management. Per the American College of Obstetricians and Gynecologists (ACOG), late peri-menopausal patients may be treated with cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device (IUD), or cyclic hormone therapy. The ACOG further noted that women who have completed childbearing, in whom medical therapy has failed, or who have contraindications to medical therapy are candidates for hysterectomy without cervical preservation. Appropriate treatment includes an endometrial ablation or hysterectomy. Endometrial ablation is not definitive therapy and is generally considered for premenopausal women. This patient was treated with conservative management, which was hormonal therapy appropriate for her age. Given the ACOG recommendations for patients who have failed conservative therapy in this clinical setting, the hysterectomy performed on 1/16/17 was medically necessary for treatment of this patients post-menopausal bleeding. Based on the foregoing discussion, the surgery at issue was 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 56-year-old male enrollee has requested reimbursement for a polysomnography performed on 4/27/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees snoring. The physician reviewer found that in this case, the patient presented with multiple symptoms strongly suggestive of obstructive sleep apnea, both on the basis of his reported symptoms and his medical history. While polysomnography has traditionally been used to evaluate patients with obstructive sleep apnea, there has been a paradigm shift towards testing for obstructive sleep apnea in the home environment. As a result, it has become more common to test patients with suspected obstructive sleep apnea with unattended sleep testing. Such testing has been shown to be equally beneficial in terms of the establishment of obstructive sleep apnea as lab testing in a less intense environment. In this case, there is a lack of documentation of any contraindications to unattended testing. Given that there has been a change in this diagnostic paradigm towards ambulatory testing, the services that were performed exceeded the patients clinical needs. Thus, the polysomnography performed on 4/27/15 was not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.