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

Summary Reviewer 1

A 19-year-old female enrollee has requested reimbursement for electromyography (EMG) and electroencephalogram (EEG) monitoring during spine surgery performed on 12/05/19. 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 intraoperative neurophysiologic monitoring is the standard of care for intraoperative detection of emerging iatrogenic complications of scoliosis surgery, and to prevent its progression and to possibly reverse it by making adjustments during surgery. The monitoring needs to be total, as in this case. Combined sensory and motor evoked potentials monitoring must be regarded as the least neurophysiological standard for intraoperative detection of emerging spinal cord injury during corrective spinal deformity surgery. Early detection affords the surgical team an opportunity to perform rapid intervention to prevent injury progression or possibly to reverse impending neurologic sequelae. Iatrogenic spinal cord injury is the most feared complication of scoliosis surgery. Based on the medical evidence, the monitoring in this case was medically appropriate. Therefore, EMG and EEG monitoring during spine surgery performed on 12/05/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found the herpes zoster vaccine is recommended for people age 60 years and older by the Centers for Disease Control. Patients with a diagnosis of rheumatoid arthritis who are on methotrexate, steroids, azathioprine or 6-mercaptopurine or are expected to receive high level immunosuppressive therapy are eligible to receive the vaccine if they are greater than 50 years of age. This patient does not qualify under these criteria. The diagnosis of rheumatoid arthritis or lichen planus in itself is not an indication for vaccination.  In sum, the shingles vaccine performed on 2/06/17 was not likely to have been superior over other treatment options in this patients case.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 46-year-old female enrollee has requested reimbursement for Botox injections provided on 7/8/15 and 11/6/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found there is a lack of documentation provided for review regarding the nature and character of the patients headaches. Per the current medical literature, the following drugs are known to be effective in the prophylactic treatment of headaches antiepileptic drugs, antidepressants, beta-blockers, calcium channel antagonists, serotonin antagonists, botulinum neurotoxins, [nonsteroidal anti-inflammatory drugs] NSAIDs, and others (including riboflavin, magnesium, and Petasites) (Silberstein, et al). A meta-analysis by Jackson and colleagues noted that, single trials found no differences between botulinum toxin A and amitriptyline. Based on these findings, it cannot be concluded that the Botox injections performed were more effective than other standard therapies for the patients condition.Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 52-year-old male enrollee has requested reimbursement for proton beam therapy provided from October through December 2016. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees nasopharyngeal carcinoma. The physician reviewer found that currently, there is insufficient data to suggest the superior efficacy of proton beam therapy in this clinical setting. At this time, further data through prospective clinical trials is needed regarding cases in which the target is the primary volume located near critical structures. Whether or not proton therapy (in general) affords any benefit over conventional radiation therapy is a controversial issue with quite disparate opinions among experts in the field. The medical literature suggests that the benefit from proton beam therapy is primarily in the head and neck cancers in which the target directly abuts critical structures like skull base tumors. There are preliminary dosimetric studies, which suggest that proton beam therapy may be better at sparing pharyngeal constrictor muscles spinal cord, parotid glands, larynx, and brainstem. However, the issue of whether dose reduction to any of these structures beyond what intensity modulated radiation therapy (IMRT) can achieve, is still undecided. For most head and neck cancers, IMRT should be able to readily spare the salivary glands, pharyngeal constrictors, spinal cord, brainstem, mandible and other normal tissues. The medical evidence for sinonasal tumors is encouraging, but further data is needed. As such, proton beam therapy provided from October through December 2016 was not likely to have been superior to IMRT or other standard modalities for evaluating this patients medical condition.  Therefore, for the reasons stated above, the services at issue were not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/10/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the breast tomosynthesis performed on 2/10/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the documentation submitted for review and medical literature, the use of breast tomosynthesis 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 19-year-old female enrollee has requested reimbursement for mental health inpatient services provided from 3/23/15 through 8/24/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found considering this patients formidable psychiatric history, significant affective symptoms with psychosis, suicidality and drug use, a conservative hospitalization was reasonably expected to improve her condition and prevent a more serious episode of illness.  However, based on the medical records, services at the acute level of care were only necessary through 5/9/15. Discharge on 3/22/15 would have been premature and more than likely would have resulted in undue morbidity and prompt readmission. The patient was reported to be isolative, hallucinating and picking at her self-inflicted wounds. Her medications were not yet optimized and her disposition was uncertain. Thereafter, the patient struggled with apprehension, anxiety, depression, auditory hallucinations and suicidal ideation. By late-April, a trend of sustained mood improvement began to emerge.  On 4/22/15, her mood was okay with no behavioral dysregulation or skin picking. It was the first day she was described as pleasant rather than depressed. On 4/24/15, the patient was less irritable and not as angry. She was consolidating the notion of conservatorship, taking her medication without issue and participating in all unit activities. In the days that followed she was described as bright and playful. On 4/20/15, placement was pending, suggestive that the illness burden was approaching appropriateness for an alternative setting. By 5/9/15, the prolonged disposition process had declared itself as the primary source of the patients frustration and apprehension.  She was eating well and sleeping well, and maintaining her activities of daily living. She had unimpaired cognitive faculties. Her mood was euthymic. She had not been suicidal or psychotic in nearly three weeks, while her depression had lifted as well. She was adherent with medications which were well tolerated. Although the patients chronicity warranted ongoing treatment, she was no longer suffering from an acute psychiatric syndrome.  Based on the documentation provided, safe, appropriate and adequate treatment could have reasonably been conducted at a less restrictive setting, such as a residential treatment facility, as of 5/10/15.  Thus, mental health inpatient services provided from 3/23/15 through 5/9/15 were medically necessary, but not thereafter. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 65-year-old male has requested reimbursement for gene testing performed on 12/09/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found this patient has a low risk prostate cancer and likely has a significant life expectancy.  The medical evidence supports Oncotype DX prostate cancer testing post-biopsy for patients with very-low-risk and low-risk prostate cancer at diagnosis with 10 to 20 years life expectancy.  In this clinical setting, the services at issue were likely to be more beneficial than not performing the test and pursuing aggressive therapy.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 65-year-old male with a history of melanoma involving the right axillae. He has a history of a melanoma in the chest in 2016. The physician reviewer found that the National Comprehensive Cancer Network guidelines recommend that patients with metastatic melanoma have tissue sent to ascertain alterations in BRAF, and in the appropriate clinical setting, KIT from either biopsy of the metastasis (preferred) or archival material, if the patient is being considered for targeted therapy. Consideration of broader genomic profiling is recommended if the test results might guide future treatment decisions or eligibility for participation in a clinical trial. Given the patients advanced disease, molecular profiling was medically indicated. Therefore, targeted genomic sequence analysis, DNA 324 genes (0037U) performed on 2/20/19 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 35-year-old female enrollee has requested authorization and coverage for surgical jaw reconstruction. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the medical necessity for the requested surgical jaw reconstruction has not been established in this clinical setting. The patient presents with a class II malocclusion and has been recommended to undergo orthodontic appliances and double jaw surgery. However, a clear functional deficit related to this malocclusion that has failed reasonable conservative management and would likely improve with complex surgical intervention has not been adequately defined in the medical documentation. The patient complains of discomfort and intermittent pain. However, it is not clear from the requesting surgeon that this is from the malocclusion and that this would likely improve with surgical correction, as he states that this may or may not improve with jaw repositioning and correction of her occlusion. In addition, based on the photographs, the patient does not have evidence of significant disfigurement from her malocclusion and overjet. Therefore, the requested procedures are not considered medically necessary, as there is not a well-defined functional impairment that would likely improve with surgical intervention. Moreover, based on the photographs submitted for review, the patient does not have evidence of significant deformity to warrant surgical correction on a reconstructive basis.
Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested reimbursement for testosterone injections provided from 4/25/16 through 6/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees low testosterone. The physician reviewer found that this patient has low testosterone levels. Based on current medical literature, the low level and the patients symptoms were adequate to justify the three intramuscular testosterone injections. Intramuscular therapy is one way of replacing testosterone in hypogonadal men (Morley; Shoskes, et al). While topical gel therapy is preferred by most providers and patients over intramuscular injections, the latter is a standard therapeutic means of replacing testosterone in patients with low testosterone. All told, the testosterone injections provided from 4/25/16 through 6/6/16 were medically necessary for treatment of this patients low testosterone. Based on the foregoing discussions, 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: Overturned

Summary Reviewer 2

A 57-year-old female enrollee has requested reimbursement for comprehensive cancer genomic panel provided on 5/9/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees rectal carcinoma. The physician reviewer found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines, KRAS, NRAS, and BRAF mutations, and microsatellite instability (MSI) markers may provide some guide toward possible treatment options. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (Benson, et al). Thus, the KRAS, NRAS, BRAF, MLH1, MSH2, MSH6 and PSM2 portions of the testing performed on 5/9/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the testing 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, a portion of 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 partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 62-year-old male who presented with complaints of severe low back pain. Past surgical history was positive for L4/5 and L5/S1 laminectomy. The physician reviewer found that this patient presents with persistent severe mechanical back pain. Functional limitations are noted in activities of daily living. Clinical examination findings have documented pain with lumbar flexion and extension. He is neurologically intact. He is status post prior laminectomies at the L4/5 and L5/S1 levels. There is imaging evidence of degenerative disc disease at L4/5 and L5/S1. There is radiographic evidence of 4 mm spondylolisthesis at L4/5. He has failed to improve with conservative treatment, including activity modification, medications, and physical therapy. Evidence-based peer-reviewed literature supports the use of lumbar fusion for patients with severe degenerative disc disease and spondylolisthesis. Given the patientas significant mechanical pain, failed conservative treatment, imaging findings of reportedly severe degenerative disc disease at L4/5 and L5/S1, prior lumbar laminectomy at both levels, and spondylolisthesis at L5/S1, the request for lumbar fusion surgery is supported to improve pain and restore function. Therefore, the requested lower back fusion is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 8/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 8/9/16 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 service 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a 14-year-old male enrollee has requested authorization and coverage for Norditropin Flexpro 15 mg/1.5. 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 was already between the 5th and 10th percentile before starting treatment. His growth velocity had already started to improve before the start of growth hormone therapy, suggesting that he might have constitutional delay of growth and puberty, and ultimately started to have pubertal growth spurt. There is no clear documentation of Tanner staging for the patient. It seems there was period of slow growth in 2019, which could be due to pre-pubertal slow down, which is a normal physiological phenomenon. His height/growth potential was always maintained, as the predicted adult height has been either in range or above the range of his target height. Therefore, Norditropin FlexPro 15 mg/1.5 is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 35-year-old male enrollee has requested authorization and coverage for jaw surgery.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the medical literature documents mixed results in attempting to correct moderate to severe obstructive sleep apnea with jaw surgery.  The surgical goal is to advance the jaws to increase the size of the pharyngeal airway space.  It was stated that a mandibular repositioning appliance, found to be effective in treatment of mild obstructive sleep, was not an option due to the patients orthodontic treatment.  These appliances work on the premise that advancement of the mandible will cause a resultant increase in the pharyngeal space by moving soft tissue obstruction, thus opening the airway.  It is thus counterintuitive that a setback of the mandible as prescribed would allow effective treatment of the obstructive sleep apnea as the movement of the jaw is opposite to that of the mandibular advancement appliance.  All told, the requested jaw surgery is not medically indicated for the treatment of this patient.  Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 39-year-old male with persistent PLA2R titer and persistent nephrotic syndrome. The records indicate that the patient previously responded to anti CD-20 therapy with rituximab. The patient has requested authorization and coverage for obinutuzumab (Gazyva) injections. The Health Insurer has denied this request indicating that the requested medication is considered investigational. Gazyva is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Currently, there is a lack of clinical trials showing that Gazyva is effective for treatment of membranous glomerulonephritis. In addition, rituximab has been demonstrated to more efficiently deplete CD-20 and is likely beneficial in this patient. Thus, the requested obinutuzumab (Gazyva) injections are 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 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.