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

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested authorization and coverage for private duty nursing. The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollee, who has been diagnosed with spinal muscular atrophy. The physician reviewer found the submitted documentation supports the medical necessity of the requested services.  Spinal muscular atrophy is an autosomal recessive progressive disorder with multiple phenotypic presentations. Children with this diagnosis are typically severely disabled and wheelchair-bound. Scoliosis and severe gastroesophageal reflux eventually occur, with risk for aspiration, pneumonia, and malnutrition. Intelligence is generally normal. This patient with spinal muscular atrophy has a number of skilled nursing needs as detailed above. He is at risk for aspiration with resultant pneumonia and skin breakdown. He requires aggressive respiratory care, including airway clearance to prevent pneumonia, close observation during feeding to prevent aspiration, and assistance with all aspects of daily living, including application of supplemental oxygen and administration of medications. Based on his current clinical situation, the requested private duty nursing is medically necessary. 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: Upheld

Summary Reviewer 1
A 61-year-old female enrollee has requested reimbursement for the molecular profiling lab testing performed on 1/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic carcinoma of unknown primary site. The physician reviewer found thatalthough it is important to determine the tissue of origin so that the proper therapy could be applied, in this case, there were numerous tests ordered piecemeal with no specific rationale. In retrospective studies, molecular profiling based on gene expression has been demonstrated to be highly accurate in determining the tissue of origin (Bender and Erlander). The Pathwork Tissue of Origin test is similar to the test provided in this case, but is strongly supported by a large multicenter clinical trial (Monzon, et al). All told, there was more conventional testing to adequately evaluate this patients CUP and the additional molecular profiling lab testing performed on 1/23/15 was not likely to be more beneficial for evaluation of the patients medical condition than any the available standard tests. Based upon the information set forth above, I have determined 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: Upheld

Summary Reviewer  
 
The patient is a 46-year-old female who presented to her provider on 8/23/21. The examination 
findings included that the patients sensation was grossly intact. The patient has requested 
reimbursement for CPT 97016-GP application of vasopneumatic device provided on 9/08/21, 
9/09/21, 9/13/21, 9/15/21, 9/20/21, 9/22/21, 9/28/21 and 9/29/21. The physician reviewer 
found that the submitted documentation fails to demonstrate the medical necessity of the device 
at issue.  In a letter dated 8/23/21, the provider cited 33 studies. All journal articles cited were 
reviewed. Additionally, an independent literature review was performed. Of the journal articles 
provided for review, none discussed the use of vasopneumatic compression for complex regional 
pain syndrome. Smart and colleagues recommended a multimodality approach to treat complex 
regional pain syndrome. However, despite the numerous treatment options they discuss, they 
do not discuss the use of vasopneumatic compression. Similarly, Harden and colleagues do not 
mention vasopneumatic compression in the treatment of complex regional pain syndrome. There 
is  a  lack  of  peer-reviewed  published  literature  that  has  a  control  group  demonstrating 
improvement in complex regional pain syndrome when compared with standard treatment 
options. Guidelines support a combination of medication, physical modalities, interventional, and 
psychological treatment to address complex regional pain syndrome. There is a paucity of 
literature  support  for  the  use  of  vasopneumatic  compression  for  complex  regional  pain 
syndrome.  Furthermore,  the  documents  provided  indicated  that  the  vasopneumatic 
compression  was  intended  to  address  edema  and  paresthesia,  but  neither  of  these  were 
identified in the records provided. Therefore, CPT 97016-GP application of vasopneumatic device 
provided on 9/08/21, 9/09/21, 9/13/21, 9/15/21, 9/20/21, 9/22/21, 9/28/21 and 9/29/21 was 
not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 62-year-old male enrollee has requested reimbursement for a wearable cardioverter defibrillator performed on 7/25/18, 8/25/18 and 9/25/18. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is sufficient support for the device at issue in this case. The records document a history of percutaneous coronary intervention with recent onset symptomatic non-ischemic cardiomyopathy. Catheterization showed a patent left anterior descending artery stent and left ventricular dysfunction out of proportion to his residual mild coronary artery disease, consistent with a new non-ischemic cardiomyopathy. His medical therapy was increased. There is some likelihood of recovery of left ventricular function in this instance over the initial three-month period with evidence-based medical therapy. Although implantable cardioverter defibrillators have been shown to be beneficial in both ischemic and non-ischemic cardiomyopathy, this patient did not meet criteria for implantable cardioverter defibrillator. The current medical evidence recommends a minimum of three months of evidence-based medical therapy of left ventricular dysfunction, and then reassessment of ejection fraction prior to consideration of implantable cardioverter defibrillator. The patient was at risk for malignant arrhythmia and sudden death while his ejection fraction was low. A wearable cardioverter defibrillator can provide temporary protection from sudden death due to arrhythmia in this patient population during this interim period. Therefore, the wearable cardioverter defibrillator provided on 7/25/18, 8/25/18 and 9/25/18 was likely to have been more effective than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The patient is a 66-year-old male with a history of leg achiness, tightness, swelling, skin discoloration and heaviness for five years. His body mass index (BMI) is 39. The patient is documented as having worn compression stockings for more than five months without perceived benefit. An ultrasound report noted reflux in the bilateral short saphenous vein (SSV) and reflux in the bilateral medial distal calf perforator veins. The bilateral greater saphenous vein were noted to have been ablated. There was no evidence of deep vein thrombosis (DVT). The provider recommended radiofrequency ablation of bilateral SSV and bilateral medial distal calf perforator veins as well as ultrasound guided injections of varicose vein tributaries. The patient has requested authorization and coverage for endovenous vein ablation. The Health Insurer has denied this request indicating that the requested services are considered investigational. Consensus indications for radiofrequency ablation include venous diameter within 2-20 mm, reflux time of 0.5 or more seconds, and distance from the skin 5 or more mm, or subfascial location. There are insufficient level 1 or level 2 studies in the literature to demonstrate that radiofrequency ablation of perforators is appropriate and a lack of evidence to support perforator surgery in the absence of stage 5 and 6 chronic venous disease. Overall, the current guidelines do not support the requested endovenous vein ablation for treatment of this patients medical condition.  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 2

A 56-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845). The Health Insurer has denied this request indicating that requested procedure is considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes. The physician reviewer found that the documentation provided does not support the superior efficacy of the requested procedure in this clinical setting. It is not clear from the record whether this patient may benefit from conversion from sleeve gastrectomy to duodenal switch. The conversion cannot be determined without ensuring that this patient has been adequately evaluated and prepared for the different nutritional consequences ,including the need for fat soluble vitamins. The records provided do not document that this patient has been assessed behaviorally as to the increased potential risks related to re-operative surgery or that she has been deemed an appropriate candidate for the requested procedure. Both nutritional and psychological evaluations should be initiated. Therefore, biliopancreatic bypass with duodenal switch (CPT code 43845) is not likely to be superior to the available methods of treating this patients medical condition. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 56-year-old female. The patient has requested authorization and coverage for 
transcranial magnetic stimulation (TMS) treatment services. 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 physician reviewer found 
that the submitted documentation supports the medical necessity of the requested services. In this 
case, the patient has tried and failed first-line medications including fluoxetine, sertraline, and 
fluvoxamine, as well as clomipramine, a second-line agent. The patient has also tried and failed 
duloxetine and escitalopram. From a therapy standpoint, the patient has failed CBT and exposure 
therapy; both in combination with medications. The patient's OCD symptoms are chronic, severe, 
and resistant to treatment. Given that current medical literature supports the use of the TMS as an 
evidence-based intervention for selected, treatment-resistant patients such as in this clinical setting, 
the requested services are medically indicated. Therefore, TMS treatment services are medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 34-year-old female enrollee has requested reimbursement for emergency room services provided on 12/22/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that this patient presented with low back pain described as spasms. Her pain was not sudden in onset, but had commenced three days prior. The patient had not sustained any recent trauma. She denied any systemic symptoms. The patient was not experiencing any acute neurologic deficit. Because this patients back pain was not acute in nature and was without any systemic symptoms or deficits, it does not meet prudent layperson criteria for an emergency. The patients symptoms on 12/22/17 did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health. Therefore, the Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this patients case. Biofeedback/neurofeedback is not generally recognized for the treatment of attention deficit/hyperactivity disorder. Holtmann and colleagues reported stringent meta-analysis of eight randomized controlled trials published in 2013 found that the effects were stronger for unblinded measures and three recent subsequently published well-controlled trials found no effects for the most blinded attention deficit/hyperactivity disorder outcome. Firmer conclusions must await upcoming evidence from larger controlled studies and future meta-analyses contrasting different forms of neurofeedback and different outcome measures. In a meta-analysis by Cortese and colleagues, the authors concluded that the evidence currently fails to support neurofeedback as an effective treatment for attention deficit/hyperactivity disorder. The authors noted future efforts should focus on implementing standard neurofeedback protocols, ensuring learning, and optimizing clinically relevant transfer. In sum, biofeedback treatment services provided from 3/05/18 through 5/14/18 was not likely to have been superior over other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 50-year-old female enrollee has requested authorization and coverage for ultrasound ablation. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees uterine fibroids. The physician reviewer found the two most common symptoms of uterine fibroids are abnormal uterine bleeding and pelvic pressure. The most common kind of abnormal bleeding associated with leiomyomas is heavy or prolonged menstrual bleeding. Hysterectomy remains the most common surgical treatment for fibroids because it is the only definitive treatment that eliminates the possibility of recurrence. HIFU is a noninvasive approach uses high-intensity ultrasound waves directed into a focal volume of a leiomyoma. The ultrasound energy penetrates soft tissue and produces well-defined regions of protein denaturation, irreversible cell damage, and coagulative necrosis. Although short-term studies show safety and efficacy, long-term studies are needed. There is a lack of well-designed clinical studies evaluating the safety and efficacy of HIFU using relevant outcome measures are lacking. Studies have generally lacked comparison to the currently accepted treatments of uterine myomas (Chittawar and Kamath). In addition, the published evidence regarding HIFU does not adequately address the potential for regrowth of treated myomas over time, especially beyond three years. In conclusion, given the lack of well-designed randomized controlled trials with adequate follow-up periods and appropriate outcome measure, ultrasound ablation 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 61-year-old male enrollee has requested authorization and coverage for Androgel. 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 in this case, the patient has symptoms of hypogonadism and one test result available consistent with low testosterone level. The records do not document a second test confirming the low testosterone. The records do not document whether there was a diagnostic work-up for hypogonadism, such as determining whether it is primary or secondary. The records do not show whether this patient has been counseled regarding the possible side effects of testosterone replacement, or that he is being monitored. It is recommended that complete blood count, a prostate-specific antigen (PSA) level or a prostate examination be done prior to starting therapy and to monitor after initiation of testosterone. The patient is on Proscar, which is a medication for treatment of enlarged prostate and benign prostatic hyperplasia. It is well-documented that testosterone replacement might contribute to prostate cancer. Therefore, patients at risk for prostate cancer should avoid testosterone replacement therapy and should be evaluated by a urologist. Thus, Androgel is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 19-year-old male enrollee has requested reimbursement for residential treatment services provided from 11/13/14 through 12/22/14.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found in this patients case, despite pharmacotherapy with antipsychotic and antianxiety agents, the patient was irritable and anxious with poor eye contact, limited insight and a blunted affect.  He endorsed somatic delusions of having toxins in his body, which was likely an extension of his assertion that he had an eating disorder.  He also complained of chronic headaches and gastrointestinal distress.  During the disputed course of treatment, the patient demonstrated signs of clinical improvement and was engaged in active treatment.  Regarding the former, the patient was described by nursing as anxious and isolative with ongoing bodily concerns and affective restriction.  However, in mid-December 2014, the patient started to appear more positive, more relaxed and more social, which is consistent with the consolidation of treatment gains.  In terms of treatment, the patient benefited from milieu, group, individual and family therapies on the unit.  His diagnostic assessment, which had included multiple rule outs upon admission, was determined with far greater certainty.  The services provided during the disputed timeframe were for active treatment and were reasonably expected to improve his condition and prevent a more serious episode of illness.  Thus, residential treatment services provided from 11/13/14 through 12/22/14 were 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 63-year-old male enrollee has requested reimbursement for the Foundation One test performed on 3/13/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees metastatic poorly differentiated carcinoma. The physician reviewer found that the Foundation One test analyzes 200 oncogenes and tumor suppressor genes for mutations by next generation sequencing. The results can assist providers in selecting treatment towards these mutations. Von Hoff and colleagues reported on a study of 86 patients where the progression free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The authors found that the regimen selected by molecular profiling offered a 27% survival advantage. Two clinical trials compared cabozantinib to placebo and showed that the drug extended PFS, decreased opiate use in patients, treated soft tissue and bone lesions, and decreased markers of bone turnover (Smith, et al; Goodin and DiPaola). Given this support, the Foundation One test provided on 3/13/16 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: Experimental
Decision: Overturned

Summary Reviewer 1


A 56-year-old female enrollee has requested reimbursement for Oncotype DX colon cancer assay completed on 8/19/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that there is support in the medical literature for the services at issue in this clinical setting. Oncotype DX assay is a 12 gene panel that predicts the risk of recurrence in both stage II and III colon cancer (Yothers, et al; Yamanaka, et al). Moreover, a review by You and colleagues supported the use of Oncotype assay in the decision about adjuvant chemotherapy. Most oncologists make this decision based on specific pathologic and clinical features in an individual's situation. Among those features that predict for a higher risk of recurrence are poorly differentiated histology, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor. Of these features, only the fact that there was perforation at the time of diagnosis is applicable in this patients case. This factor alone does suggest the possible need for adjuvant chemotherapy. This test is useful in a situation wherein there is an adverse feature (perforation), upon which to base the decision for chemotherapy. All told, the use of Oncotype DX colon cancer assay completed on 8/19/15 was likely to be more effective than the standard options for the evaluation of this patient. Therefore, for the reasons stated 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.