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

Summary Reviewer 2

A 59-year-old male enrollee has requested reimbursement for the UroLift procedure performed on 4/3/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees elevated prostate specific antigen (PSA) and enlarged prostate with lower urinary tract symptoms. The physician reviewer found that the UroLift procedure has been approved as an effective treatment of appropriately selected patients 50 years or over with BPH. UroLift has shown to be successful and relatively safe in the short-term. There is good quality evidence to establish the efficiency of UroLift in treating symptomatic BPH without adversely affecting the quality of life. Based on the current literature, UroLift can be considered as an option for those symptomatic BPH patients with small or medium size prostates defined as less than 80 mL without median lobe enlargement, who failed on medical therapy or are intolerant to it and wish to preserve their sexual function. This patient was initially evaluated for erectile dysfunction. All told, the UroLift procedure performed on 4/3/17 was 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 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

A 43-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 7/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Foundation One assay is a molecular assay of gene mutations found in a variety of cancer cells. The hope is that the assay will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic drug would be useful. Thus far, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is clinically beneficial. Le Tourneau and colleagues did not demonstrate better efficacy when choosing therapy based on such an assay versus the oncologists clinical judgment. In this patients case, the initial treatment was based on the oncologist common practice without the need for Foundation One assay results. In sum, FoundationOne CDx testing performed on 7/16/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 61-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 considered investigational for treatment of the enrollees colorectal cancer with liver metastases. The physician reviewer found that the potential benefit of proton therapy over photon therapy lies in its potential ability to spare normal tissue adjacent to the treatment volume. While proton therapy appears superior to photon therapy dosimetrically, it does not always translate into a clinical benefit. There is a paucity of randomized or retrospective trials supporting proton therapy in the treatment of rectal cancer. The lack of studies for proton cancer in rectal cancer is likely due to the fact that proton therapy excels in clinical scenarios where there is a sharp border between the radiation target and normal tissue, especially if it occurs in a tight space. This is not the clinical scenario for rectal cancer. The treatment volume for rectal cancer is relatively large, and includes the entire rectum and the mesorectum. The main acute side effect of radiotherapy for rectal cancer is diarrhea, and is due to the fact the entire rectum receives the full dose of radiation. Because the rectum is the target of radiotherapy, it is not possible nor desirable to spare the rectum from radiation. The other structures that may be of concern in sparing for rectal radiation are the small bowel and bladder. Given that the dose tolerance for the small bowel is 50 Gy, and that the dose required in a palliative setting should be below 50 Gy, there is no perceived benefit to proton therapy in sparing the small bowel from a dose below tolerance. Moreover, proton therapy is not recommended in the National Comprehensive Cancer Network (NCCN) guidelines for rectal cancer. For these reasons, the requested proton beam radiation therapy 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 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 3

A 36-year-old male enrollee has requested authorization and coverage for implantation of hypoglossal nerve stimulator. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees sleep apnea. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. OSA is an increasingly prevalent clinical problem. 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 Stimulation Therapy for Apnea Reduction (STAR) trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA (Woodson, et al). This trial demonstrated that hypoglossal nerve stimulator is safe and effective in a small subset of patients with OSA who have failed CPAP. With a BMI of 31.9, AHI of 43.9 and nonconcentric airway collapse, this patient meets the criteria. He has failed CPAP which is the gold standard treatment for OSA and has also failed upper airway sleep surgery. He remains at risk for untoward cardiac sequelae of untreated OSA. All told, implantation with a hypoglossal nerve stimulator is likely to be of greater benefit than the standard modalities for treatment of this patients medical condition. Therefore, for the reasons stated 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 1

A 60-year-old female enrollee has requested authorization and coverage for a heart monitor (implantable ambulatory event monitor). The Health Plan has denied this request indicating that the requested device is considered investigational for treatment of the enrollees syncopal episodes. The physician reviewer found that based on the records provided the patient is a 60-year-old female with infrequent syncope recently resulting in head trauma and negative short-term evaluation for culprit arrhythmias. In this setting, prolonged monitoring for a dysrhythmic cause of the patients syncope is reasonable, appropriate and considered standard accepted practice in the medical community. Prolonged monitoring cannot be feasibly obtained with any monitoring device other than an implantable device such as a LINQ monitor. This approach has shown to be more effective than standard monitoring in identification of a cause and is now incorporated into current guidelines (Strickberger, et al; Krahn, et al; Brignole, et al). Therefore, the request for a heart monitor (implantable ambulatory event monitor) 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 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: Overturned

Summary Reviewer 


The parent of an eight-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that a nonsystematic review concluded that for best practice a minimum of 20 hours a week of intervention over two years, taking account of each childs strengths and weaknesses and family circumstances, was essential for young children with autism to make gains (Smith, et al; Roberts). In this case, the patient is in the first grade and is already having a school day of at least six hours. The request for 40 hour per week of ABA is excessive and may be detrimental of the desired effect. Therefore, based upon the medical literature and the documentation submitted for review, 20 hours per week of ABA therapy, 13 hours per month of supervision and four hours per month of parent training provided from 4/29/16 through 10/29/16 were and are medically necessary for treatment of the patients medical condition. Therefore, a portion of the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 21-year-old male enrollee has requested reimbursement for polymerase chain reaction testing performed on 6/07/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient appears to have had chronic prostatitis and was evaluated and treated with several antibiotic regimens. Per the records, gonorrhea and chlamydia testing was negative.  His symptoms seem to improve, but returned after cessation of antibiotics. The urine was then sent for DNA analysis. It is standard of care to obtain bacterial, viral and fungal cultures for the diagnosis and management of prostatitis. DNA analysis is not the standard of care for this evaluation. In sum, polymerase chain reaction testing performed on 6/07/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested authorization and coverage for Xeljanz. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that available treatment options for alopecia areata are quite limited. This is especially true for diffuse/multifocal involvement, where standard therapies such as topical steroids, intralesional Kenalog, contact immunotherapy and conventional immunosuppressants are more often than not less than satisfactory and associated with side effects. Although there is no significant data yet from randomized clinical trials (which are currently underway), there is substantial clinical evidence to support the use of oral Janus kinase inhibitors such as tofacitinib for alopecia areata. In one open label pilot study, eight of 12 patients demonstrated approximately 50% hair regrowth as measured by Severity in Alopecia Tool (SALT) scoring. There have been minimal adverse effects reported to date. Moreover, these results are better than what has been reported for contact immunotherapy and systemic steroids. Therefore, Xeljanz is likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested authorization and coverage for Butrans.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for treatment of the enrollees pain. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The Health Insurer has denied coverage for Butrans. The Health Insurer requires history of failure or intolerance to the step one alternative drugs. These are Belbuca, tramadol extended release, and morphine sulfate controlled release tablets. In this patients case, a trial of Belbuca is medically appropriate and reasonable.  Belbuca is the same drug as the patient is requesting, but in a form that dissolves in the buccal cavity.  It is approved by the U.S. Food and Drug Administration for treating severe pain.  Similar to Butrans, Belbuca has been shown to have efficacy and safety in chronic pain patients. Additional studies support the efficacy of Belbuca in this clinical setting.  All told, Butrans is not medically necessary for the treatment of this patient.  Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 26-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment provided from 1/28/18 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 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 lack of suicidal ideation. With regards to functional status, the records support a score of 3 due to overall fair functional level at home with some issues with daily activities. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability and some history of substance use issues. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable living environment with family members. In terms of level of support of the recovery environment, the records support a score of 2 due to an overall supportive recovery environment and family that is supportive of his treatment. With regards to treatment and recovery history, the records support a score of 3 due to moderate response to past treatment. In terms of engagement and recovery status, the records support a score of 2 due to cooperation in treatment. Thus, the patient has a composite score of 15. This score correlates with low-intensity community-based services. Therefore, the records do not demonstrate the medical necessity of residential treatment. In sum, residential treatment from 1/28/18 and ongoing was not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 46-year-old female enrollee has requested authorization and coverage for total disc arthroplasty (CPT 22858 and 22856).  The Health Insurer has denied this request indicating that the requested services are investigational for treatment of the enrollees medical condition. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  This particular implant has been approved for two-level use.  Most of the literature indicates an initial advantage to cervical disc replacement compared to anterior cervical discectomy and fusion.  However, long-term results of both procedures are similar or there is a slight advantage to total disc arthroplasty.  Davis and colleagues noted that four-year results from their study continued to support total disc replacement as a safe, effective, and statistically superior alternative to anterior cervical discectomy and fusion for the treatment of degenerative disc disease at two contiguous cervical levels.  In sum, the requested total disc arthroplasty is likely to be of greater benefit than other treatment options.  Therefore, as 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 patient is a 61-year-old female diagnosed with attention deficit hyperactivity disorder (ADHD), binge eating disorder and malabsorption syndrome status-post gastric bypass surgery. The patient had reportedly been on lisdexamfetamine (Vyvanse) since 2012. In 2017, it appears that medication became less effective, lasting no more than four hours. On Vyvanse 70 mg three times a day (TID), the dose was well tolerated, with no insomnia or other side effects. The patient has requested authorization and coverage for Vyvanse 70 mg TID. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational. 
Stimulant medications, like Vyvanse, are first-line therapies for ADHD. This patients records document that she has been diagnosed with ADHD and binge eating disorder. The current dose of Vyvanse was achieved after a systematic reasonable titration due to her comorbid conditions. The decreased bioavailability and lowered absorption of orally administered drugs in this clinical setting is common due to the bypassing of the duodenum, proximal jejunum and majority of the stomach. The medication dose appears to be both efficacious and well-tolerated, with no evidence that it is unsafe. The medication is approved by the FDA for the conditions being treated. The treatment is optimizing functionality and minimizing the patients illness burden. It is the recommendation of the treating provider to continue the medication at the current dose. The patient desires to continue the treatment. Considering all aspects of this patients case, the requested Vyvanse 70 mg TID 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 medication dosage 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: Overturned

Summary  
The patient is a 61-year-old male. In a letter dated 12/8/22, the provider reported that the patient 
presented with a variety of neurological symptoms and was initially evaluated in Japan in August 
2018 with a diagnostic angiogram that showed a lesion. The patient has requested authorization 
and coverage for the PET with CT scan. The Health Insurer has denied this request and reported 
that the requested services are not medically necessary for the evaluation 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. PET-CT scans are 
invaluable in determining whether a skull base lesion is of neoplastic origin or vascular origin. The 
surgical approach and treatment of these two possibilities are vastly differently so as to profoundly 
increase the importance of accurate, pre-intervention diagnosis. Chang and colleagues note that 
combined with high specificity and patient convenience, dotatate PET/CT should be considered 
the ideal first line investigation for imaging neuroendocrine tumors. In this clinical setting, given 
that current medical literature supports the use of dotatate PET/CT in a standard work-up of this 
patient, the requested services are medically indicated. Therefore, the PET with CT scan is 
medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
  A 52-year-old male enrollee has requested reimbursement for ExoDx Prostate/ExosomeDx 
Prostate (Intelliscore) performed on 12/23/20. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollees 
medical condition. The physician reviewer found that the ExoDx Prostate/ExosomeDx Prostate 
(Intelliscore) is a noninvasive liquid biopsy that quantifies three RNA targets in urine exosomes. 
The urine exosome gene expression assay is associated with improved identification of patients 
with higher-grade prostate cancer among men with elevated PSA levels and could reduce the 
total number of unnecessary biopsies. Despite these findings, currently there is not enough 
clinical evidence that this testing can be utilized instead of prostate biopsy to diagnose prostate 
cancer. This patients prostate ultrasound was unremarkable. This patient has risk factors for 
developing prostate cancer. Furthermore, PSA levels can be misleading due to testosterone 
replacement therapy. There is a lack of support for the services at issue in this clinical setting. 
Therefore, ExoDx Prostate/ExosomeDx Prostate (Intelliscore) performed on 12/23/20 was not 
likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 32-year-old male enrollee has requested authorization and coverage for RT300 therapy system. 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 Locked-in syndrome is a very rare condition characterized by paralysis of almost all muscles that are under voluntary control (except, classically, for the muscles responsible for vertical eye movements), while consciousness and cognition remain intact. The condition is often mistaken for a vegetative state. In this case, the patient had bilateral brainstem strokes in 2011, which is the typical etiology responsible for a locked-in state. As of May 2016, he had recovered to a level where he had essentially normal left upper limb strength. He had weak but functional right upper limb strength. He was able to perform some functional tasks with assistance. He was mute/aphonic, but communicating with the assistance of an application on his mobile phone.  The patients most recently described functional status in the available documentation is not compatible with persistent locked-in syndrome. An upper body functional electrical stimulation cycle ergometer has been recommended for the patient. There is no indication, however, that the patient could not use a standard upper body cycle ergometer for exercise, i.e., without the functional electrical stimulation component. There is some weakness in the right upper limb, but left upper limb strength is essentially intact. There is a lack of published data that establish a benefit of use of the device in question for the patients condition. It is not a proven adjunct or substitute for active exercise using volitionally intact muscles in the setting of this patients condition. It is not reasonably expected to improve function, health or incidence of complications. Therefore, the requested RT300 therapy system is not medically necessary for the treatment of this patient.