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

Summary Reviewer 

The parent of a 16-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. 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 the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient did not meet generally accepted diagnostic criteria for idiopathic short stature because his height has been above -2.25 standard deviations. This patient was not growth hormone deficient based on normal growth hormone responses to two provocative tests, normal IGF-1, and normal IGFBP-3 on 10/28/15. Standard of care for suspected growth disorders includes direct height measurements of both biologic parents whenever possible, since self-reported histories can be unreliable. Based on the patients recent bone age of 14 to 15 years, height 62.91, testosterone of 323.2 ng/dL and Tanner stage IV development, he is likely to attain at least his mid-parental target height of 64.5.  His growth pattern, mildly delayed bone age before puberty, and mildly delayed pubertal onset are most consistent with normal variations of pubertal timing. There is a lack of support for the requested medication in this clinical setting. Therefore, Humatrope 24 mg cartridge is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 63-year-old female enrollee has requested reimbursement for digital breast tomosynthesis provided on 1/21/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 1/21/16 was likely to have been superior over other modalities for evaluating this patient.  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: Experimental
Decision: Upheld

Summary Reviewer 3

A 34-year-old female enrollee has requested reimbursement for the gene test provided on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for heart disease. The physician reviewer found that while some providers have advocated for routine use of advanced lipoprotein analysis, the most recent guidelines from the American College of Cardiology (ACC) do not support testing in this clinical setting. Rather, the guidelines recommend standard lipid profile testing and standard risk factor assessment to determine risk and management of future heart disease. This patient did not present with a history of cardiovascular disease or an increased risk of cardiovascular disease. For these reasons, the gene test provided on 3/17/16 was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 92-year-old male who has a history of a stroke in June 2015, attributed to atrial fibrillation. The patient has requested reimbursement and prospective authorization and coverage for home health care services from 5/08/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are 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 patient returned home in May 2020 after inpatient rehabilitation following a hospitalization for pneumonia with placement of a gastrostomy tube due to dysphagia. At that point, he was no longer new to gastrostomy tube feeds, and an enteral nutrition therapy and medication administration plan should have been established in the rehabilitation facility for transition to the community environment, which is a routine practice. There were no indications that he was not tolerating administration of his feeds and medications through this route. His bolus tube feeds were spread out, which is the typical manner in which bolus tube feeds are administered. This level of care did not require a registered nurse or licensed practical nurse to perform on a long-term, routine basis in the community setting. There was one documented instance when the feeding tube was not working (e.g., 5/19/20), but he could have been taken to an emergency room by a caregiver or other custodial level provider, just as the nurse did, for further evaluation and care. The patient did not have wound care or other needs that required skilled nursing services during the time period in question, based on the available documentation, outside of the two periods when he was being administered medications parenterally for infections (i.e., from 8/12/20 through 8/22/20 and 9/06/20 through 9/20/20). Gauze placed at the gastrostomy stoma site is not a skilled nursing need. Patients can develop stoma site issues, such as infections, whether or not this routine stoma care is provided by a skilled provider. In this case, despite the provision of this service by a skilled provider, the patient developed an ESBL infection at his stoma site. He was otherwise largely performing his self-care on his own. Any assistance that he received with respect to routine self-care, e.g., related to incontinence, would have been custodial. Chronic lymphedema can be managed with compression stockings and intermittent pneumatic boot therapy, but routine application of these appliances can be performed by individuals/caregivers and is not a skilled nursing need. Therefore, a portion of the home health care services from 5/08/20 forward was medically necessary. Specifically, home skilled nursing services from 8/12/20 through 8/22/20 and 9/06/20 through 9/20/20 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested authorization and coverage for peroral endoscopic myotomy (POEM) and associated inpatient admission. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees esophageal achalasia. The physician reviewer found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient is status post orthotopic liver transplant and has evidence of achalasia. In this clinical setting, treatments include laparoscopic Heller myotomy with partial fundoplication and POEM. Because the patient is status post orthotopic liver transplant with a history of bile leak, Heller myotomy is likely contraindicated. As such, the request for POEM and associated inpatient admission 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the radiofrequency ablation is an accepted treatment that can be included in the standard of care when treating chronic back pain. The patient has symptoms consistent with facet mediated pain and has undergone prior radiofrequency ablation. She continues to perform an independent home exercise program and is limited in terms of medication tolerance. Recent imaging showed an improvement in the previous L5-S1 disc herniation consistent with the time since previous imaging as well as the patients commitment to exercise and conservative treatments. The two-level right-sided procedure proposed is supported by the patients reported symptoms. The patient had a positive response to radiofrequency ablation performed in December 2015. The current request for repeat radiofrequency ablation is more than six months after the prior treatment. Based on the clinical documentation submitted for review, the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service 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: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a 14-year-old male enrollee has requested authorization and coverage for the ReWalk Exoskeletal Device durable medical equipment (DME). The Health Insurer has denied this request indicating that the requested equipment is investigational for treatment of the enrollees T8 incomplete spinal cord injury due to spinal tumor.  The physician reviewer found that based on the available medical literature, the requested ReWalk device is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The U.S. Food and Drug Administration (FDA) approval allows the use of this device by the public with a physicians prescription. However, the benefits with respect to health and mobility in the setting of this condition have not been conclusively established. The published data are scarce and low quality (Lajeunesse, et al). The ReWalk device is an adjunctive mobility device that is less efficient and less reliable than standard mobility devices. For these reasons, the requested ReWalk Exoskeletal Device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 57-year-old male with a medical history of human immunodeficiency virus (HIV) 
infection with associated cachexia. The patient has requested authorization and coverage for 
Serostim (somatropin (non-refrigerated) for subcutaneous injectable 6 mg). The physician 
reviewer found that Serostim has been approved by the U.S. Food and Drug Administration 
(FDA) for use in adults with a diagnosis of growth hormone deficiency, HIV-associated wasting, 
cachexia or short bowel syndrome. There is a high prevalence of anorexia-cachexia syndrome in 
individuals with chronic illnesses, including advanced HIV/acquired immune deficiency 
syndrome (AIDS). In this case, the documentation does not support that the patient has HIV 
wasting, as his body mass index (BMI) is within normal limits at 28.2. Furthermore, his medical 
provider has stated his HIV is well-controlled, and there is not a medical indication for the 
requested Serostim. Therefore, Serostim (somatropin (non-refrigerated) for subcutaneous 
injectable 6 mg) is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1a.  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. Due to thrombocytopenia, this patients provider noted that he is not a candidate for treatment with interferon. All told, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. In sum, 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 2

A 28-year-old female enrollee has requested reimbursement for computer-aided detection performed on 4/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has BRCA2 gene mutation. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The Health Insurer is covering the breast MRI with contrast performed on 4/20/18, consistent with accepted medical practice for female patients with the BRCA2 mutation.  There is a lack of peer-reviewed literature supporting better outcomes when computer-aided detection is added to breast MRI in screening for patients with increased risk of breast cancer. Thus, computer-aided detection performed on 4/20/18 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: Overturned

Summary Reviewer 3 
 
A 49-year-old male enrollee has requested authorization and coverage for 0424T insertion 
neurostimulator system for central sleep apnea. The Health Insurer has denied this request and 
reported that the requested service is investigational for the treatment of the enrollees central 
sleep  apnea.  The  physician  reviewer  found  that  multiple  controlled  clinical  studies  have 
demonstrated the safety and efficacy of the Remede phrenic nerve stimulator system for the 
treatment of central sleep apnea.  The system is FDA approved for this indication. In this case, 
the patient has primarily central sleep apnea noted on formal sleep test, has not responded to  
CPAP, biPAP, or ASV, and is symptomatic with disturbed sleep and daytime fatigue. Therefore, 
0424T insertion neurostimulator system for central sleep apnea is likely to be more beneficial for 
treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 70-year-old male enrollee has requested reimbursement for an attended sleep study performed on 1/9/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that there has been a shift in the provision of care from the attended setting to the ambulatory/home environment for sleep studies. This has been accomplished through the technological advancements associated with auto-titrating continuous positive airway pressure devices (APAP and AutoPAP). These devices are used to maintain a patent oropharynx in the treatment of patients with OSA. APAP devices titrate effective airway pressure throughout the night using an algorithm that responds to physiologic signals, allowing for use outside of a sleep center. Current medical literature including randomized studies has shown that the use of an AutoPAP produces an equivalent outcome to attended CPAP titrations (Rosen, et al; Berry and Sriram; Chai-Coetzer, et al). In this case, there was no documentation provided for review that AutoPAP was trialed. He was then referred for an attended CPAP titration. Nor did the patient have any comorbid medical conditions that would be expected or to degrade the quality of an AutoPAP in the home setting. The provision of services in the laboratory setting would be considered to exceed the clinical needs and services required for the effective management of the patients condition. Such services could have been provided in a less resource intense setting as well. For these reasons, the attended sleep study performed on 1/9/17 was not medically necessary for evaluation of the 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 34-year-old female enrollee has requested reimbursement for acute inpatient mental health treatment for adults provided form 3/08/19 through 3/12/19. 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, objective instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. In terms of risk of harm, the records support a score of 1 due to a lack of current suicidal ideation. With regards to functional status, the records support a score of 2 due to overall good daily functioning while on the inpatient unit with recent resolution of self-care difficulties. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to no recent history of substance use and resolution of any possible medical issues that contributed to her initial admission presentation. With regards to level of stress of the recovery environment, the records support a score of 2 due to some issues on an intermittent basis with interpersonal conflict due to her psychiatric issues. In terms of level of support of the recovery environment, the records support a score of 2 due to supportive resources and professional supports. With regards to treatment and recovery history, the records support a score of 2 due to rapid resolution of acute symptoms. In terms of engagement and recovery status, the records support a score of 2 due to good cooperation in treatment and noted insight into the need for treatment. Therefore, the patient has a composite score of 13. According to the LOCUS, a score of 28 or greater is required for medically managed inpatient care. Therefore, acute inpatient mental health treatment for adults provided from 3/08/19 through 3/12/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 47-year-old female enrollee has requested authorization and coverage for the LINX procedure. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In the clinical records submitted for review, there is no documentation of a manometry report or pH study. In addition, there is no comprehensive description of the patients symptoms. Given the lack of adequate data provided, the LINX procedure has not 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 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 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found the gene expression profiling performed on 6/29/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the Decision Dx Melanoma assay should not be used outside of a clinical trial. Moreover, the testing at issue is not expected to impact the treatment or outcome of the patients melanoma. As such, the testing at issue was not 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 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.