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

Summary Reviewer 

A 16-year-old male enrollee has requested reimbursement for psychiatric residential treatment provided from 11/07/17 through 10/26/18. 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 in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. In terms of risk of harm, the records support a score of 1. The patient was not actively suicidal and did not engage in self harm. With regards to functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and anxiety, but overall showed appropriate daily functioning while in treatment as evidenced by intact activities of daily living and cooperation in treatment. With regards to comorbidity, the records support a score of 2. The patient did not have a history of past medical issues but had past substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have a good relationship with family and denied stress at home have of a significant nature. With regards to level of support of the recovery environment, the records support a score of 2. The patients parent were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. The patient reported no past mental health treatment of a significant nature but had some response from attention deficit/hyperactivity disorder medication in the past. With regards to acceptance and engagement of the child, the records support a score of 2. The patient participated in therapy. In terms of acceptance and engagement of the parent, the records supported a score of 2. The patients parents worked actively and constructively with clinicians. Thus, the patient had a composite score of 16.  This score correlates with outpatient services. Therefore, psychiatric residential treatment provided from 11/07/17 through 10/26/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 45-year-old male enrollee has requested reimbursement for ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19. The Health Insurer has denied this request and reported that the medications at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient was diagnosed with metastatic medullary renal cell carcinoma. Renal medullary carcinoma is a very rare cancer that arises in the kidney in patients with sickle cell trait or disease.
It comprises less than 0.5% of the total cases of kidney cancer. Its extreme rarity also makes it difficult to judge therapeutic modalities. One cannot expect a randomized clinical trial or even a phase II since there are simply too few patients. There are also no guidelines. There are anecdotal reports of durable responses to certain cytotoxic agents. The patient was started on nivolumab and ipilimumab. According to the National Comprehensive Cancer Network guidelines, for collecting duct or medullary subtypes, partial responses have been observed with cytotoxic chemotherapy Outside of clinical trials, platinum based chemotherapy regimen should be the preferred therapy for renal medullary carcinoma. Based on current guidelines and medical evidence, ipilimumab and nivolumab were not indicated for this patient. They were appropriate in the context of a clinical trial. In sum, ipilimumab and nivolumab provided on 6/11/19, 7/02/19, 7/23/19 and 8/13/19 were not likely to have been more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3
A 49-year-old male enrollee has requested reimbursement for the platelet rich plasma injection performed on 1/4/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees left foot pain. The physician reviewer found the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical literature concerning the use of PRP for treatment of musculoskeletal conditions of the foot show mixed results regarding potential benefits of PRP for musculoskeletal conditions. Sampson and colleagues reviewed PRP injections for musculoskeletal injuries, found PRP provides a promising alternative to surgery or other invasive treatment modalities. However, the authors concluded that there are too few controlled trials and sample sizes are too small. Therefore, the authors concluded that more large controlled studies are needed. In sum, there are a lack of peer-reviewed medical literature to conclude that PRP is better than any other standard treatment for musculoskeletal conditions. Therefore, the PRP injection performed on 1/4/17 was 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 service at issue was 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 2

A 59-year-old female enrollee has requested reimbursement for Decision DX melanoma assay performed on 5/19/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that melanoma is a cancer that is curable in its earliest stages.  Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm.  Metastases to regional lymph nodes may be amenable to excision, but they suggest a high risk for the development of metastatic disease in the future.  Such patients may be observed or treated with interferon-alpha.  The data on the Decision DX melanoma assay has not made it part of routine analysis after sentinel lymph node biopsy.  There has also been some lack of consistency between various genes being used as biomarkers.  The test is very novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques.  Therefore, Decision DX melanoma assay performed on 5/19/16 was not likely to have been more efficacious than other methods of 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 1

The parent of a 16-year-old female enrollee has requested authorization and coverage for ceftriaxone sodium injection. The Health Insurer has denied this request indicating that the requested medication is at investigational for the treatment of the enrollees Lyme disease. The physician reviewer found per Infectious Disease Society of America practice guidelines and the peer-reviewed literature, there is a lack of data to support the use of IV ceftriaxone therapy for more than four weeks for the treatment of Lyme disease. Also, the patients diagnosis of Lyme disease is not definitive based on the clinical documentation submitted for review. Given the lack of documentation of support for a diagnosis of Lyme disease and the lack of data supporting prolonged therapy with ceftriaxone sodium injection, the requested medication is not clinically indicated. Based upon the information set forth above, the requested medication 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 2


A 20-year-old male enrollee has requested authorization and coverage for chondrocyte implantation with Denovo. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of large volume, long-term, peer-reviewed outcome studies to support the safety and effectiveness of the chondrocyte implantation with Denovo for the treatment of focal articular defects of the patella.  In this case, the patient presents with pain emanating from his left knee patellofemoral joint and a well-circumscribed defect in the posterior patella medially.  Detailed evidence of a recent comprehensive nonoperative treatment protocol trial or previous operative treatment and failure has not been submitted.  Given the absence of evidence-based, peer-reviewed support for the use of Denovo chondrocyte implantation, the superior efficacy of the requested services has not been established.  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: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the services at issue were not likely to be more beneficial for treatment of the patients medical condition than other modalities. There is a lack of medical literature supporting the services at issue in this clinical setting. According to Holtmann and colleagues neurofeedback has gained some promising empirical support in recent years from controlled studies as a treatment of core ADHD symptoms. However, a recent stringent meta-analysis of 8 randomized controlled trials published in 2013 found that the effects were stronger for unblinded measures and 3 recent subsequently published well-controlled trials found no effects for the most blinded ADHD outcome. The authors concluded that Firmer conclusions must await upcoming evidence from larger controlled studies and future meta-analyses contrasting different forms of neurofeedback and different outcome measures. In sum, neurofeedback therapy for the treatment of ADHD is not the standard of care and was 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 1

A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/11/15.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Based upon the information set forth above, the services at issue were 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: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 37-year-old female with a history of pelvic pain, fibroid uterus, and dysfunctional uterine bleeding.  She has a history of abnormal Pap smears that required excisional procedures.  She had an Essure device placed for permanent contraception. For the complaint of pelvic pain and dysfunctional bleeding, she has tried conservative treatment with combined oral contraceptive pills and progesterone only pills. She did not have success with either of these medications in treating her complaints. The patient has requested authorization and coverage for an abdominal hysterectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The patient has longstanding pelvic pain and dysfunctional uterine bleeding in the setting of an Essure placement.  The patient meets the standard indications for hysterectomy: 1) uterine leiomyomas, 2) abnormal uterine bleeding, and 3) pelvic pain. She has tried conservative treatment without success. In addition, the Essure may be contributing to her pelvic pain. Studies have shown a 10-fold risk of reoperation after the placement of Essure for both pelvic pain and irregular bleeding. This patient has a history of excisional biopsies for cervical dysplasia.  Per the records, the appropriate treatment for this patient is total hysterectomy including the cervix so that she is not at risk for additional cervical disease or bleeding from the remaining cervix, both which are common. The fallopian tubes should also be removed to include the Essure device. Thus, the requested abdominal hysterectomy is medically necessary for the treatment of this patient. Therefore, the requested services are 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 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient presents with a history of constant severe left knee pain with associated swelling, buckling and instability. Significant functional limitations are documented in mobility and activities of daily living. She has a history of multiple dislocations and multiple surgical attempts to correct her patellar instability. She underwent left knee arthroscopy, debridement, chondroplasty, chondral biopsy, synovectomy and removal of loose bodies on 7/27/18. Operative findings documented a 2.0 x 2.0 cm (4.0 cm2) chondral defect of the lateral facet of the patella, and lateral tilt and subluxation of the knee cap. She also had a 1.5 x 1.5 cm chondral defect of the anterolateral trochlea. She had failed extensive long-term operative and non-operative treatment, including activity modification, bracing, ice, medications, and ambulatory assistive devices. The treating provider has opined that she was not a candidate for standard operative therapy including microfracture, osteochondral autograft or allograft transplant (OATS), or total knee arthroplasty given her age and lesion size. Under consideration is a request for matrix associated chondrocyte implantation (MACI) for the left knee. There is current evidence-based medical literature support for the use of autologous chondrocyte implantation in patellar defects as safe and effective with documented long-term outcomes. There is evidence that MACI offers a more efficacious alternative than microfracture with a similar safety profile for the treatment of symptomatic articular cartilage defects of the knee. Osteochondral allograft and autograft transplantation is limited to defects measuring 2.5 cm2 or less. Therefore, the requested autologous chondrocyte implantation of the knee is likely to be more beneficial for treatment of the patients medical condition that 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: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that Chromosomal microarray (CMA) is recommended by the American College of Medical Genetics as a first-line test for patients with autism spectrum disorders. The yield of CMA in patients with autism spectrum disorders is estimated to be around 10%. While findings on CMA may not alter treatment of the features associated with autism spectrum disorders in all patients, CMA has become the standard of care in this clinical setting. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with neuropsychological treatments or medications that have been shown to be more efficacious in this patient population. Additionally, copy number variations on CMA may inform about possible other complications and medical risks. All told, the FirstStepDx PLUS test provided on 7/6/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for residential and mental health treatment provided from 4/01/14 through 5/20/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  During the dates of service in dispute, there was no evidence of the patient being a danger to herself or others, no evidence of self-injurious behavior or urges, and no aggression towards others.  There was no evidence or documentation of eating disorder behaviors, no weights, and no intake monitoring.  She had no substance abuse problems.  She was engaged and an active participant in the treatment process, as were her parents.   She was redirectable and open to suggestion.    She was independent in her activities of daily living, and there were no cognitive difficulties.   She was medically stable and tolerated medication changes without difficulty.  Amantadine was helpful for impulsivity. However, this did not require a structured residential setting for institution and maintenance.  There was a glaring paucity of documentation to support the necessity of this level of care, and the treatment she received did not meet criteria for residential level of care in terms of hours of treatment.  Although this patient required ongoing intensive psychological and psychiatric care for psychotherapy and medication management, she did not require supervision in a 24-hour per day, seven days per week structured setting.  All told, residential and mental health treatment provided from 4/01/14 through 5/20/15 were not medically indicated for the treatment of this patient.  Therefore, 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: Overturned

Summary Reviewer 1

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/9/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination. The physician reviewer found that there is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to have been more effective than had her examination been performed using two dimensional imaging alone. Based upon the information set forth above, the service 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 42-year-old male enrollee has requested authorization and coverage for lumbar total disc arthroplasty (artificial disc). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found per the current medical evidence, the superior efficacy of the requested services has not been established.  The clinical documentation submitted for review indicated the patient had undergone diagnostic studies including an MRI, a CT scan of the lumbar spine, and electrodiagnostic studies.  The patient was treated with physical therapy, acupuncture, selective nerve root blocks, and medications.  However, the peer-reviewed literature indicates the use of artificial disc replacement requires further studies.  All told, the requested lumbar total disc arthroplasty (artificial disc) is not likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.