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

Summary Reviewer 

A 24-year-old female 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 hepatitis C virus. The physician reviewer found in managing patients with chronic HCV denying treatment because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions.  Moreover, post hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have less than 6,000,000 IU/mL viral load can be treated with an eight week course of Harvoni, instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni should be approved as medically necessary based on national guidelines. For the reasons provided, the requested medication is 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 59-year-old female enrollee has requested reimbursement for a cooling or combined cooling/heating device. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees medical condition. The physician reviewer found the use of continuous flow cryotherapy for reduction of postoperative swelling and pain has become commonplace in knee and shoulder surgery.  However, prolonged exposure to extreme cold may induce an injury identical to that of frostbite.  Therefore, continuous flow cryotherapy is not recommended for ankle and foot surgery.  Complications related to cryotherapy are rare but can be devastating.  They include chronic pain, frostbite, and loss of digits.  Cold packs are effective and are generally recommended after foot and ankle surgery.  Based upon a review of the literature, the device at issue was not likely to have been superior over other treatment options.  Based upon the information set forth above, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2
A 54-year-old female enrollee has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT). The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that Groheux and colleagues reported that when a recurrence is depicted or a patient is suspected of having a recurrence by using conventional imaging, PET/CT is useful to determine whether this recurrence is isolated or not, and such a determination may have a potential effect on the patients treatment. Manohar and colleagues found that PET/CT is a very sensitive and specific imaging tool in detecting and restaging recurrent breast carcinoma. It can be a very useful imaging tool for restaging locoregional recurrences, and as a one-stop shop imaging technique to confirm suspicious metastatic disease on conventional imaging and to define the total burden of disease. Thus, there is support in the literature for the use of PET/CT to follow-up this patients left internal mammary lymph nodes, suspicious for having breast carcinoma metastases. Based upon the information set forth above, I have determined the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 47-year-old male enrollee has requested authorization and coverage for vestibular stenosis repair. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee, who has a history of nasal congestion and obstruction. The physician reviewer found that the patient had obstruction of nasal breathing. He underwent previous nasal surgery to restore nasal breathing which included valve repair. Based on the records, it was unclear if the previous surgery was on the internal or external nasal valve. The internal nasal valve is the narrowest area of the nose where turbulence of the inspiratory and expiratory current takes place. Internal valve collapse can lead to nasal obstruction. It is characterized by the collapse during inspiration of the upper lateral cartilages; a narrowing of the angle between the dorsal septum and upper laterals can also contribute, but to a lesser extent. Functional rhinoplasty procedures for internal nasal valve have evolved over the past decade. Placement of precise cartilage grafts have been demonstrated to provide support which improves nasal breathing. The external nasal valve is formed by the columella, the nasal floor, and the nasal rim (or caudal border of the lower lateral cartilage). Cartilage grafting can also support the external valve. Absorbable implants for lateral cartilage support in patients with nasal valve collapse have been developed. There are limited studies supporting the use of these implants. At this time, the requested vestibular stenosis repair 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 45-year-old male enrollee has requested reimbursement for inpatient admission at a non-participating facility from 11/13/16 through 11/14/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees acute appendicitis. The physician reviewer found that the inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the physician is unsure about the patients need for inpatient admission and requires time for short term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this patients case, he was admitted in stable condition and could have been treated at an observational level of care. He had a laparoscopic appendectomy without any complications.  This procedure does not have to be performed on an inpatient only basis. Pain control was adequate after the surgery, and the patient tolerated an oral diet. The submitted documentation demonstrates that this patient could have been treated at a lower level of care. As such, admission at a non-participating facility from 11/13/16 through 11/14/16 were not medically necessary for treatment of the patients medical condition. 
Therefore, for the reasons stated above, 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: Upheld

Summary Reviewer 

A 52-year-old female enrollee has requested authorization and coverage for a PET scan. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines recommend conventional imaging of the chest, abdomen and pelvis using computed tomography (CT) as well as a radionuclide bone scan every two to six months for patients with recurrent breast cancer to the chest wall and solid organs as surveillance. PET/CT is usually is done when there are equivocal or suspicious findings suggestive of metastatic disease. The physiologic nature of a PET scan is used to confirm or exclude likely tumor recurrence. Piva and colleagues noted that PET/CT imaging can be useful when there are equivocal findings on conventional imaging. In this patients case, the medical necessity of PET/CT every three months has not been established since there has been no evidence of distant metastases in the past, and there are no conventional imaging reports after recent surgical and radiation treatment to suggest equivocal or suspicious findings. Therefore, the requested PET scan is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 34-year-old male has requested authorization and coverage for multileaf collimator device. 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 in general, IMRT is not an experimental technique, but rather a radiation planning and delivery tool available to the radiation oncologist to better shape the radiation dose distribution, and therefore minimize the dose to normal structures. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure.  There are emerging data for the use of IMRT for Hodgkins lymphoma. The rationale to use IMRT includes relative sparing of the lungs, heart, salivary glands, and other tissues. In select patients, IMRT may significantly reduce the dose to these structures.  However, 77338 is billed for the treatment planning and not the treatment delivery, and it is billed once per plan.  Thus, the superior efficacy of the requested 45 units of 77338 has not been established.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 58-year-old man with type 2 diabetes. The patient has requested authorization and coverage for Ozempic 2 mg/1.5 mL pen injectors. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that Ozempic is a member of  the glucagon-like peptide 1 (GLP-1) analogs, a new class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Additionally, recent studies have demonstrated a significantly lower rate of cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke among patients receiving Ozempic. Based on the submitted records, this patient is an excellent candidate for Ozempic. Therefore, Ozempic 2 mg/1.5 mL pen injectors are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 15-year-old male enrollee has requested reimbursement for mental health residential services provided from 1/10/18 through 4/20/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. On 12/29/17, the documentation noted that the patient had purchased knives and a taser gun. However, these records are from admission. The records for the disputed timeframe indicated evidence of low risk of harm. Additionally, this note had minimal objective evidence. This record does not document that violent acts or self-harm were committed. In terms of functional status, the records support a score of 2. The patient has demonstrated episodic failure to achieve expected levels of functioning in relationships with family and peers. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or active substance use issues. In terms of level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. With regards to level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. In terms of resiliency and treatment history, the records support a score of 3. It appears that the patients major depression symptoms were under good control with minimal signs or symptoms. He continued to have oppositional behaviors. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient was able to establish positive relationships with clinicians despite oppositional behaviors. In terms of acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 16. This score correlates with intensive outpatient services. Therefore, mental health residential services provided from 1/10/18 through 4/20/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 46-year-old female insured has requested authorization and coverage for lymphedema surgery 
and two inpatient bed days. The Health Insurer has denied this request indicating that the requested 
services  are  considered  investigational  for  treatment  of  the  insureds  lymphedema.  
The  physician  reviewer  found  that  Garza  and  colleagues  noted  that,  Lymphaticovenular 
anastomosis (LVA) or lymphovenous bypass is a surgical procedure where lymphatic vessels in a 
lymphedematous limb are connected to nearby small veins and venules using microsurgical and 
super-microsurgical techniques. The authors found that Numerous studies have been published 
which show improved symptoms and as much as 61% reduction in volume difference of the 
affected limb after LVA at one year. In addition, Pereira and colleagues reported that LVA is an 
effective treatment option to reduce the volume in the affected limb and to improve associated 
symptoms. Moreover, Cheng and colleagues concluded that LVA was performed and the patients 
remained in an inpatient setting for up to three days to allow for an adequate stabilization of the 
anastomosis before being discharged. Overall, LVA is an established microsurgical technique for 
the treatment of patients with lymphedema. LVA can be employed as a second stage after 
liposuction removal of thick lymphedematous tissue for debulking or as an inpatient surgical 
procedure to allow for careful observation, positioning, and mobilization after the procedure. 
Therefore, the requested lymphedema surgery and two inpatient bed days is likely to be more 
beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories
based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. 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, and 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. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 65-year-old male who was diagnosed in March 2015 with prostate cancer. At that time, he was found to have bone metastases. He was initially treated with radiation therapy, androgen deprivation therapy, and docetaxel, then enzalutamide. With progression, he was treated with cabazitaxel, but there was no response with this therapy. The provider had recommended cabozantinib for treatment. The patient has requested authorization and coverage for Cabometyx (cabozantinib) 60 mg #30/30. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of this patients medical condition.  Cabozantinib is a tyrosine kinase inhibitor that has been approved for use in renal cell carcinoma but not prostate cancer. This therapy with cabozantinib is not within National Cancer Comprehensive Network guidelines for treatment of prostate cancer. This patients provider proposed using it in this patient based on some very early phase studies in prostate cancer as well as a theoretical belief that it might be useful in those patients with a MET mutation, which this patient has. However, there is limited data that confirms clinical benefit in the use of this therapy for patients who are diagnosed with prostate cancer. The provider had also noted the lack of clinical benefit from these early studies.  Furthermore, the presence of the MET mutation is not an indication that there is a reasonable likelihood of response to cabozantinib. Accordingly, at this time, cabozantinib is not likely to be of greater clinical benefit for the treatment of this patient than any other standard form of therapy.  Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that the use of device closure of patent foramen ovale for prevention of cryptogenic stroke has been the subject of much research study over a long period. Current guidelines from 2014 do not recommend patent foramen ovale closure. New studies suggest that there may be a change in guidelines, but a change has not yet taken place. Of note is that some studies emphasize high-risk patent foramen ovale which involves a larger shunt, size over 2 mm, atrial septal aneurysm or mobile septal motion, none of which was documented in this patients case. Thus, heart surgery (93580, percutaneous transcatheter closure of heart defect) is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 68-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/06/17. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is an assay of 31 genes in an individuals melanoma cells. It then classifies that melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. However, it is not clear how the five-year DecisionDx-Melanoma data compares to the 10-year Balch data. Furthermore, it is not clear if the DecisionDx-Melanoma assay classification can be used to make clinical decisions. In sum, DecisionDx-Melanoma testing performed on 12/06/17 was not likely to have been more efficacious than other methods of evaluating this patient.