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

Summary Reviewer 

The parent of a 17-year-old transgender female enrollee has requested reimbursement for gender reaffirming surgery performed on 7/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The records document a history of gender dysphoria. The Health Insurer denied reimbursement for gender affirming surgery performed on 7/26/18. The Health Insurer noted that coverage is provided for this procedure for patients who are 18 years of age or older, and this patient was 17 years of age at the time of surgery. World Professional Association for Transgender Health (WPATH) recommendations are flexible, taking into account the best interests of the patient. There has been considerable experience with transgender youth having vaginoplasties under age 18. In fact, it is often a better time, while the child is still living with parents, who can care for her in the perioperative period. This patient has a long history of stable transgender identity, and the experts caring for her felt that she had the maturity to make the decision to have vaginoplasty, and that it was in her best interests to have the surgery at age 17 rather than waiting until 18. Thus, gender reaffirming surgery performed on 7/26/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported 
pain in her left knee that she rated at an eight out of a scale of ten. The patient has requested 
reimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this 
request and reported that the services at issue were not medically necessary. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the services at issue. Per the medical literature, 
although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is 
not known as to which individuals will benefit. The current evidence is limited, and guidelines 
from organizations such as the American Academy of Orthopedic Surgeons indicate that the 
evidence  is  not  conclusive.  In  light  of  the  foregoing,  viscosupplementation  can  only  be 
recommended in individuals with a history of lasting benefit from prior injections, and in carefully 
selected cases where everything else has been tried, and the options are limited. In this case, the 
patient reported pain at a level of eight out of ten that did not respond to a corticosteroid injection 
on 3/17/22. The patient had tried and failed other conservative treatments. Given the patients 
limited options and based on the current medical literature, the services at issue were medically 
indicated. Therefore, Synvisc from 6/15/22 through 6/29/22 was medically necessary for the 
treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 50-year-old male enrollee has requested authorization and coverage for Prevymis (letermovir). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who is status post heart transplant. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient underwent a recent heart transplantation and has mild leukopenia. Although valganciclovir is known to be associated with leukopenia, other medications that the patient has been prescribed are also associated with leukopenia, such as Bactrim. The leukopenia present is not clearly due to valganciclovir. In addition, letermovir is approved for patients with hematopoietic stem cell transplant patients and has not been sufficiently evaluated in solid organ transplantation. Finally, bone marrow suppression also occurs using letermovir in the form of thrombocytopenia in up to 27% of patients. For these reasons, letermovir is not recommended prophylaxis for the management of cytomegalovirus in solid organ transplant recipients. Thus, Prevymis (letermovir) is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 52-year-old female enrollee has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that proton therapy is well-established in dosimetric superiority and precision over photon therapy due to its Bragg peak. However, this dosimetric benefit does not always translate into a clinical benefit. An example of this lack of benefit is with prostate cancer, where proton therapy has the same rate of side effect as photon therapy. This is because the local organs at risk (bladder and rectum) have a high dose tolerance to radiation. This is not true for esophageal cancer, where the lung is very sensitive to radiotherapy. The decision on the benefit of proton radiotherapy for esophageal cancer should be made on a case-by-case basis. In this patients case, the treating provider submitted a comparison plan between photon radiotherapy and proton radiotherapy. Specifically, it was demonstrated that there was a V5 of 100% in the photon plan compared to less than 20% with the proton plan. The study by Allen and colleagues indicated that a V5 of greater than 90% is associated with a 46% rate of fatal radiation pneumonitis. Thus, proton beam therapy is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 41-year-old male enrollee has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found according to Lipham and colleagues, Sphincter augmentation with the LINX Reflux Management System provided long-term clinical benefits as demonstrated by reduced esophageal acid exposure, improved GERD-related quality of life, and cessation of dependence on PPIs, with minimal side effects. Patients with inadequate symptom control with acid suppression therapy may benefit from treatment with sphincter augmentation. The LINX device is U.S. Food and Drug Administration (FDA) 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. In this case, the patient presents with GERD based on pH recording. His GERD has proven refractory to medical management, and thus he is expected to benefit from anti-reflux procedures, specifically the LINX device. In addition, the patient does not have any contraindications such as large hiatal hernia, esophageal dysmotility, Barrett's esophagus or cancer. Therefore, the requested services are 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

The patient is a 42-year-old female who presented with a history of blood in her stool for at least six months. The patients medical history also includes nephrolithiasis. The colonoscopy note dated 10/13/17 reports finding of a 15 mm rectal polyp removed with snare cautery polypectomy, a 5 mm rectal polyp removed with a cold forceps, many small-mouthed diverticula in the sigmoid, transverse, and ascending colon, and a non-thrombosed external hemorrhoid on perianal examination. Per the patients letter, she has a family history of colon polyps. She reported that she underwent a colonoscopy and polypectomy on 10/13/17, and on 10/17/17, she had a large amount of bleeding 15-20 times, including near-syncope at 3:30 in the morning on 10/18/17. She presented to the hospital on 10/18/17. Per the emergency department note, the patients initial vital signs were normal. Per the hospital stay records, her initial hemoglobin was 11.2 g/dL, which decreased to 10.5 g/dL a few hours later. She was treated with one liter of intravenous fluids and she was discharged on 10/18/17. Per the gastroenterology consultation note dated 10/20/17, she had post-polypectomy bleeding, but did not require transfusions or sigmoidectomy. The patient has requested reimbursement for the one day acute inpatient stay provided on 10/18/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary. In this case, the patient presented with a significant amount of bleeding following colonoscopy and polypectomy and marked anemia. Bleeding after snare cautery polypectomy can be severe, and therefore requires close monitoring. This condition may also require urgent intervention, including surgical or angiographic intervention when severe (Pasha, et al; Kim, et al; Jang, et al). Although the intensive care unit level of care was not needed given the patients normal vital signs, the inpatient level of care was appropriate given the rapidity of the bleeding and decline in hemoglobin. For these reasons, the one day acute inpatient stay provided on 10/18/17 was medically necessary for the treatment of this patients hematochezia.  Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 14-year-old male enrollee has requested authorization and coverage for Nutropin AQ Nuspin 10 mg/2mL (5 mg/mL) subcutaneous pen injector. 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 thaat the submitted documentation supports the medical necessity of the requested medication. This patient has had a gradual decline in his growth velocity, as shown on the growth chart. His current height is -2.98 standard deviations below the mean for age and sex. This is severe short stature. The Pediatric Endocrine Society supports the use of growth hormone for the treatment of short stature that is below -2.25 standard deviations. Thus, this patient has severe short stature that meets this criterion for treatment. Per the records, his estimated adult height prediction gradually deteriorated over time on serial bone age studies, which indicates abnormal growth. The patient is not likely to meet his genetic potential with such a poor growth velocity. His estimated adult height is significantly below his mid-parental target height. His height deteriorated despite improvement of his weight, which indicates abnormal growth beyond what can be explained by poor nutrition. Therefore, Nutropin AQ Nuspin 10 mg/2mL (5 mg/mL) subcutaneous pen injector is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 52-year-old male enrollee has requested authorization and coverage for Entyvio (J3490). The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found Entyvio (vedolizumab) is a humanized monoclonal antibody that targets a protein called alpha-4-beta-7, an integrin on inflammatory cells that causes these cells to adhere to the gastrointestinal tract. Entyvio is specifically indicated for adults with moderately to severely active ulcerative colitis (UC) or Crohn's disease (CD) who have had an inadequate response with, lost response to, or were intolerant to a tumor necrosis factor (TNF) blocker or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependence on corticosteroid. Entyvio is indicated to induce and maintain clinical response/clinical remission, achieve corticosteroid-free remission and improve the endoscopic appearance of the mucosa (UC). In a meta-analysis of biologic agents, which included vedolizumab and the TNF-inhibitors infliximab, adalimumab, and golimumab, there was no conclusive evidence that any one was more effective than any other in maintaining clinical remission in patients with moderate to severe ulcerative colitis (Danese, et al). In this case, the clinical records neither evidence a severely active flare of ulcerative colitis, nor treatment failure to conventional agents, for which vedolizumab is U.S. Food and Drug Administration (FDA) indicated. In this clinical setting, based on provided documentation Entyvio is not medically necessary for treatment of the patients medical condition. Based upon the information set forth above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 40-year-old female with a history of breast cancer. On 7/01/19, she underwent a bilateral mastectomy with bilateral deep inferior epigastric perforator (DIEP) flap reconstruction. The physician reviewer found that the DIEP flap was for breast reconstruction and was medically necessary. However, the service in dispute in this case is code 15734. Code 15734 describes muscle, myocutaneous, or fasciocutaneous flap, trunk. This code is used in the setting of ventral hernia repair or for repair of wide diastasis recti. The medical records do not support this code in this patientas case. Based on the submitted medical records, there was no ventral hernia repair or repair of wide diastasis recti reported. Per the submitted records, no abdominal weakness or hernia was reported as being present to require a separation of parts repair. Therefore, 15734-59-62 and 15734-62 performed on 7/01/19 were not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old female enrollee has requested reimbursement for A0431 ambulance service - conventional air services - transport one way provided on 12/1/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees sore throat and fever. The physician reviewer found that air ambulance services are supported as medically necessary when a patient meets specific criteria. These circumstances include when the point of pickup is inaccessible by land or there is a great distance or obstacle involved in land transport. Another circumstance is when the time needed to transport the patient by land poses a threat to a patients survival or the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one facility to another in order to receive specialized services. In such a case, the patient must be transferred to the closest facility capable of providing the specialty services. In this case, the patient presented with pneumonia status post lung transplant requiring anti-rejection immunosuppressive medications. The patient was at elevated risk for developing a rejection of her transplanted lungs and it was critical that she be treated in a facility capable of managing such complications. CMC did not have the specialty services to provide inpatient care for this patient and the documentation suggests that CUH was the closest facility capable of providing the appropriate level of care. The time necessary to transport the patient by ground ambulance would have been at least six hours, which would have posed a danger to this patient, who was tachypneic, had a central venous access and required supplemental oxygen. Given these findings, the A0431 ambulance service - conventional air services - transport one way provided on 12/1/17 were medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 48-year-old female who presented for a colonoscopy on 12/29/21. The patient 
has requested reimbursement for monitored anesthesia care provided during colonoscopy on 
12/29/21.  The  physician  reviewer  found  that  according  to  the  American  Society  of 
Anesthesiologists  guideline  for  anesthesia  care  during  endoscopic  procedures,  monitored 
anesthesia  care  is  warranted  in  prolonged  or  painful  procedures  such  as  complex  polyp 
resections,  endoscopic  retrograde  cholangiopancreatography  or  other  biliary  procedures, 
endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored 
anesthesia care is more likely necessary in patients with failed history of moderate sedation for 
the procedure or psychological impediments to cooperation. The provided records do not 
support any of these criteria, or other criteria in the literature, such as difficult intubation, airway 
obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in 
increased  tolerance  to  sedation  medications,  age  greater  than  70,  pregnancy,  increased 
aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines 
from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike 
surgery)  consciousness  during  the  procedure  is  acceptable  and  is  the  goal  during  most 
procedures (which are performed with moderate sedation), and monitored anesthesia care is 
recommended  for  prolonged  procedures  requiring  deep  sedation,  previously  anticipated 
intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic 
variant. None of these conditions are documented. The submitted documentation fails to 
demonstrate the medical necessity of the services at issue. Therefore, monitored anesthesia care 
provided during colonoscopy on 12/29/21 was not medically necessary for the treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 21-year-old female enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization level of care provided from 9/29/15 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the episodic placement at higher levels of care is often necessary, modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience. Although the patient has likely benefitted from the disputed service, the record does not support the medical necessity of partial hospitalization programming at this time. Upon presentation, the patient was at a healthy weight. Her body mass index was within normal limits. Her electrocardiogram was normal sinus rhythm. Her blood pressure was normal as was her heart rate, except upon measurement in the supine position which routinely thereafter returned mildly bradycardic in the mid-50s. The patient did have a normal glucose initially followed by hypoglycemic readings in late September. It does not appear that the blood sugar was re-tested until early November at which time it was within normal limits.  According to the psychosocial assessment, the patient was described as eloquent, intelligent, motivated with a supportive family. On 9/10/15, the patient was started on a serotonergic enhancing medication for her mood and anxiety. On 9/23/15, the patient had a normal bone scan. On 9/24/15, the patients weight was stable. She completed 100% of her meals and snacks. She reported single episodes of purging on 9/22/15 and 9/23/15.  During her therapy session that day, she named her eating disorder and expressed re-invigorated motivation to get back on track. The therapist noted that the patient was becoming more insightful regarding her eating disorder. On 9/26/15, the patient was calm, social and comfortable at meal time. She ate 100% of her meals at a steady pace with minimal supervision. On 9/27/15, the patient had a successful dinner with her parents.  On 9/28/15, the patient was active in programming and demonstrated no eating disordered behavior. The record did not describe any medical issues or psychiatric distress.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 64-year-old female. Notes dated 9/12/22 reported that the patient had eosinophilic 
esophagitis, complicated by stricture, status post dilation, resulting in esophageal perforation 
requiring esophagectomy. The patient has requested authorization and coverage for a Botox 
(onabotulinum toxin A) injection. The Health Insurer has denied this request and reported that the 
requested services is not medically necessary for the treatment of this patient. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the requested service. Fuchs and colleagues 
report that intraoperative endoscopic injection of botulinum toxin into the pylorus during robotic-
assisted transhiatal esophagectomy is feasible, safe, and effective and can prevent the need for 
pyloromyotomy. Bagheri and colleagues note that given the need to use less-aggressive techniques 
and facilitate greater use of endoscopic methods, botulinum toxin injection may be used instead of 
pyloroplasty as a simple, effective, and complication-free method to prevent delayed gastric 
emptying. In this case, the patient had an esophageal resection and subsequent development of 
pyloric stenosis. The records noted past successful improvement with an EGD with Botox. Given 
that current medical literature supports the use of chemical pyloromyotomy with Botox as safe and 
effective, the requested service is medically indicated. Therefore, a Botox (onabotulinum toxin A) 
injection is medically necessary for the treatment of this patient.