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

Summary Reviewer 3

A 32-year-old male enrollee has requested authorization and coverage for Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 ml and Gamunex-C. The Health Insurer has denied this request and reported that the medication at issue is investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested medication. There has been a diagnosis of peripheral motor polyneuropathy. Medical records from his neurologist describes muscular atrophy and weakness, diminished distal reflexes, and no upper motor neuron signs. Headaches and autonomic dysfunction are also described. He has had treatment with Radicava, which is indicated for treatment of amyotrophic lateral sclerosis. The notes do not include electromyography/nerve conduction velocity studies or autoimmune studies. Based on the available records, the diagnosis is unclear. While motor neuropathy is commonly treated with intravenous immune globulin, there is a lack of evidence that intravenous immune globulin would be helpful for amyotrophic lateral sclerosis. Without a more distinct diagnosis, it is not possible to state that intravenous immune globulin is likely to be more effective than other therapies. Thus, Gammagard liquid (immune globulin (human) IV or subcutaneous solution 5 gm/50 mL) and Gamunex-C is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 60-year-old male enrollee has requested reimbursement for repair of anorectal fistula provided on 10/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees anal fistula. The physician reviewer found that the repair of anorectal fistula provided on 10/23/15 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue. The study by Stamos and colleagues study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug. The authors concluded Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure. The use of AFP is the best option to avoid significant anal sphincter muscle damage, and resultant fecal incontinence in this clinical setting. Therefore, AFP was the superior surgical approach for treatment of the fistula without causing significant anal sphincter damage and fecal incontinence. Accordingly, the services at issue were 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 services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 63-year-old male enrollee has requested reimbursement for dopamine transporter imaging with a single proton emission computed tomography (DaT SPECT) scan performed on 8/24/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who presented with persistent hand tremors. The physician reviewer found that there is sufficient support in the medical literature for the services at issue. While a DaT SPECT study is not required for the diagnosis of all patients suspected to have Parkinsons disease, it has been shown to be useful in cases where the diagnosis is not definitive on clinical grounds.  In this particular case, the patients provider suspected Parkinsons disease, although by the history an essential tremor would have been an alternative diagnosis.  It is imperative to provide a definitive diagnosis as treatment for essential tremor and Parkinsons disease are quite different. The treatment options for Parkinsons disease can have significant side effects. This patients diagnosis was determined and verified using this study. As such, an appropriate management approach was initiated. The literature demonstrates the use of this study in differentiating cases of Parkinsons and essential tremor.  An improper diagnosis could have led to suboptimal management and potential exposure to unnecessary side effects. Therefore, DaT SPECT scan performed on 8/24/16 was likely to have been superior to other methods of evaluating this patients medical condition. Based upon the information set forth above, the services at issue were likely to have been 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 3

A 56-year-old female has requested reimbursement for percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of urinary frequency and urgency. The physician reviewer found that percutaneous tibial nerve stimulation is considered to be an appropriate third-line salvage therapy for patient with intractable irritative lower urinary tract symptoms, including frequency and urgency incontinence. This patient did not have any urodynamic findings suggestive of overactive bladder. It appears that the patient was started on antimuscarinic therapy simultaneously with percutaneous tibial nerve stimulation. It would have been prudent for this patient to assess the outcome of antimuscarinic therapy prior to therapy with percutaneous tibial nerve stimulation. Thus, percutaneous tibial nerve stimulation performed from 5/08/18 through 8/02/18 was not likely to have been more effective than other available treatment modalities. Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 54-year-old male has requested reimbursement for Anser VDZ test provided on 7/17/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that clinically, there did not appear to be any connection between the medication and the new onset neurologic symptoms. Performing the Anser VDZ testing would not clarify whether there was a relationship, as there is no question that the patient was exposed to the drug for a long period with each infusion. This is not antibody mediated. Therefore, the presence of antibody would also not be helpful to know. Finally, there is a lack of support for the use of Anser VDZ testing to optimize reactive treatment though targeted drug measurement.  All told, Anser VDZ test provided on 7/17/17 was not likely to have been superior over 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 61-year-old female enrollee has requested authorization and coverage for Trilogy 100 noninvasive ventilator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested device in this clinical setting. Amyotrophic lateral sclerosis is a progressive neurodegenerative condition that can affect all muscles of the body, including the diaphragm. This can result in significant difficulty with breathing. The use of non-invasive mechanic ventilation has shown a survival benefit. The use of such device has become the standard of care in the management of the symptoms of amyotrophic lateral sclerosis. Therefore, the requested Trilogy 100 non-invasive ventilator is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 21-year-old male enrollee has requested reimbursement for mental health inpatient services provided from 9/13/18 through 9/19/18. 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 that the submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association (APA) guidelines note that hospitalization is usually indicated for patients who are considered to pose a serious threat of harm to themselves or others or who are so severely disorganized or under the influence of delusions or hallucinations that they are unable to care for themselves and need constant supervision or support. All of which apply to this patient on the dates of service in question. Admission for this patient from 9/13/18 through 9/19/18 was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. The current medical evidence supports the services at issue in this setting. Thus, mental health inpatient services provided from 9/13/18 through 9/19/18 were 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines states that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Thus, testing (DecisionDx-Melanoma Gene Assay) performed on 7/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for verapamil. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that penile traction therapy is a therapeutic option for men with Peyronies disease. Penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. There is paucity of clinical justification regarding the efficacy of injection therapy with verapamil. Furthermore, addition of verapamil to oral therapy or other nonsurgical therapies does not appear to provide significant improvement. In sum, verapamil is not likely to be superior over other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that as noted in the current medical literature, OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. CPAP has demonstrated excellent efficacy and low morbidity. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). The results of the STAR trial demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with OSA who have failed CPAP. In this case, the patient presents with a BMI of 31.2, AHI of 25.8 and nonconcentric airway collapse. He has also failed CPAP therapy. In this clinical setting, the request for implanted upper airway stimulation device (Inspire) has been established as 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 device is 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: Upheld

Summary Reviewer 

A 60-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees prostate cancer. The physician reviewer found that upon review of available data, the requested proton therapy is not medically necessary for treatment of this patients prostate adenocarcinoma. The Health Insurer states that the patient can be treated with photon based intensity modulated radiation therapy (IMRT). In the peer-reviewed medical literature, Trofimov and colleagues reported that dosimetric studies have shown a benefit in bladder and rectal exposure with proton therapy. However, this benefit has not been demonstrated to result in fewer clinical side effects or improved health outcomes (Sheets, et al; Coen, et al; Yu, et al; Hoppe, et al). In addition, the largest available retrospective study showed that gastrointestinal toxicity was actually higher with proton therapy when compared to photon therapy (Sheets, et al). Moreover, cancer control rates are reportedly similar with photon and proton beam radiation therapy (Coen, et al). All told, there is a paucity of scientific data demonstrating that proton beam radiation therapy is medically necessary for treatment of this patients prostate cancer. Based on the foregoing discussion, the requested services are 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 35-year-old male enrollee has requested authorization and coverage for spine fusion extra segment. 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 the patient is a 35-year-old male with a history of low back pain.  On 2/09/15, the medical records noted pain radiating down right lower extremity of three months duration.  The documentation indicated a history of right L5-S1 microdiscectomy in September 2013.  The provider noted that magnetic resonance imaging (MRI) of the lumbar spine performed in December 2014 showed recurrent disc herniation at L5-S1 with narrowing of right lateral recess.  The patient reported that two epidural steroid injections did not improve his symptoms.  He has requested coverage for spine fusion extra segment.  The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient. The submitted records fail to demonstrate the superior efficacy of the requested services.  A multilevel fusion for degenerative disc disease is not likely to be beneficial in this patients case.  In the absence of instability, for the management of failed spinal surgery syndrome, the medical evidence supports a combination of physical therapies and cognitive therapies rather than a surgical intervention.  All told, the requested spine fusion extra segment is not likely to be superior over 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A  49-year-old  male  enrollee  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the 
requested service is investigational for the treatment of the enrollees chronic low back pain. At 
issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial for 
treatment of the enrollee's condition than any available standard therapy. The physician reviewer 
found that Conger and colleagues report regarding the effectiveness of intraosseous basivertebral 
nerve radiofrequency when compared with a placebo procedure, There is moderate-quality 
evidence that suggests this procedure is effective in reducing pain and disability in patients with 
chronic low back pain who are selected based on type 1 or 2 Modic changes, among other inclusion  and exclusion criteria used in the published literature to date. In a prospective randomized 
multicenter study for basivertebral nerve ablation for the treatment of chronic low back pain, 
Koreckij and colleagues determined that disability and pain were improved at 24 months after the 
procedure. Macadaeg and colleagues reported similar results at twelve months of follow-up in a 
prospective single arm study of intraosseous basivertebral nerve ablation for chronic low back pain 
including participants who had failed six months of non-surgical treatments. In this case, the 
patient has exhausted and failed the standard treatments for vertebrogenic low back pain for over 
six months. Given that current medical literature indicates that basivertebral nerve ablation 
consistently demonstrates good results for pain relief and improved disability, the requested 
service is likely to be more beneficial for treatment of the patients medical condition than any 
available standard therapy. Therefore, intraosseous basivertebral nerve ablation is likely to be more 
beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 62-year-old male. Notes dated 9/7/21 reported that the patient presented with 
scrotal swelling and pain. The patient has requested reimbursement for an inpatient day from 
9/8/21 to 9/9/21. The Health Insurer has denied this request and reported that the services at issue 
were not medically necessary for the treatment of this patient. This denial is the subject of this 
appeal and determination. The physician reviewer found that the submitted documentation does 
not support the medical necessity of the service at issue. Generally, a patient with orchitis that does 
not have urosepsis or require surgery is treated as an outpatient or, at most, under 24-hour 
observation. In this case, however, the records note that as the patient had failed an outpatient 
course of oral antibiotics, a brief intravenous course needed to be applied prior to outpatient 
continuance of care. Given that 24-hour observation, as opposed to an actual inpatient admission, 
was appropriate the records did not document complications or that other special procedures were 
needed, the services at issue were not medically indicated. Therefore, inpatient day from 9/8/21 to 
9/9/21 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 28-year-old male enrollee has requested reimbursement for substance use inpatient detoxification provided from 7/27/17 through 8/08/17 and residential treatment provided from 8/09/17 through 9/11/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that regarding the request for residential services, on step-down, the patients vital signs were stable. He showed no post-acute withdrawal symptoms on admission to residential treatment. This is inconsistent with staffs report of ongoing post-acute symptoms which one would see in the acute phase of opioid withdrawal. As noted above, there were no emotional, behavioral, cognitive, or impulsive issues requiring a 24/7 structured setting. He was not suicidal or homicidal. There was no evidence of any psychotic thought process, mania, or any other condition which would preclude treatment on an ambulatory basis. Standard of practice in the community is medication assisted treatment, which he had previously received. Thus, substance use inpatient detoxification provided from 7/27/17 through 8/08/17 and residential treatment provided from 8/09/17 through 9/11/17 were not medically necessary 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


The guardian of a 17-year-old male enrollee has requested reimbursement for residential treatment provided from 6/05/14 through 10/11/14. 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 supports the medical necessity of the services at issue.  This patient had a history of substance abuse, truancy, running away, defiance, and risky and self-destructive behavior.  This patient engaged in the therapeutic environment, albeit he was initially resistant to change.  He reportedly showed some progress.  Given this patients level of his behavioral problems, his familys lack of ability to control him, and his defiance of authority, he was not likely to have been receptive to or cooperative with a lower level of care.  Based upon the medical records, this patient could not have effectively been treated at a lower level of care.  He needed long-term treatment for both substance abuse and behavioral health conditions in a restricted environment.  All told, residential treatment provided from 6/05/14 through 10/11/14 was medically indicated 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.