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

Summary Reviewer 

The parent of a 16-month-old female enrollee has requested authorization and coverage for hourly pediatric nursing, 12 hours per day, seven days per week (S9123). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this medically fragile patient has a number of problems as a result of, and in addition to, her cloacal abnormalities, chronic kidney disease, and prematurity. The most important issue for her at this time, prior to completion of her reconstructive surgeries, is prevention of urinary tract infection and preservation of renal function. With the introduction of skilled nursing services, she has had no further significant urinary tract infections requiring parenteral antibiotics and hospitalization. She has been able to attend preschool to aid in her development and help her to catch up to her peers. The patients mother is the primary caregiver and has significantly modified her schedule in order to provide for the patients custodial needs. She does not have the necessary expertise, however, to provide for the patients skilled medical needs, including ostomy care and prevention of urinary tract infections. The requested skilled nursing services 12 hours daily 7 days per week are essential to this patients current health as well as to the future success of her reconstructive surgeries. Therefore, the requested hourly pediatric nursing, 12 hours per day, seven days per week (S9123), is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 10-year-old male enrollee has requested reimbursement for the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20. 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 the current medical evidence supports the device at issue in this clinical setting. The RT300 FES Therapy System has been approved by the U.S. Food and Drug Administration. The patient has permanent neurological disability after a spinal cord injury. This device has been recommended as the best treatment option by his treating physicians as part of his rehabilitation program. There is medical literature supporting the device at issue in this setting. Therefore, the functional neuromuscular electrical stimulator-arms therapy system provided on 4/16/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 57-year-old female enrollee has requested reimbursement and prospective authorization and coverage for chemical dependency residential treatment provided from 2/15/19 through 2/20/19. 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 the submitted documentation supports the medical necessity of the services at issue. The American Psychiatric Association indicates that residential treatment may be indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, and who lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Patients require safe and stable living environments in order to develop their recovery skills. The purpose of detoxification is to make the patient physically stable and safe. Rehabilitation is the essential component that should follow detoxification in order to help the patient maintain sobriety and reduce the risk of relapse. Given the severity of the patients illness, including her continuing to consume alcohol despite severe hepatic impairment while on a liver transplant waitlist, residential treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patients illness. Therefore, chemical dependency residential treatment provided from 2/15/19 through 2/20/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/20/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. There is rarely any systemic surveillance imaging, further lymph node interrogation or recommendation for adjuvant therapy. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. The DecisionDx-Melanoma gene expression profile test is an expression assay designed to predict distant metastasis in stage I and stage II melanoma patients. DecisionDx-Melanoma assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as Class 1 (i.e., low risk of metastasis) or Class 2 (i.e., high risk of metastasis). However, the medical evidence has not established that DecisionDx-Melanoma testing is likely to be more effective than other standard methods of evaluating this patient. Therefore, DecisionDx-Melanoma testing performed on 2/20/18 was not likely to have been superior over other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 66-year-old man with lumbar stenosis. The patient has requested authorization and coverage for lumbar spine surgery (laminectomy, facetectomy and foraminotomy, single vertebral segment). 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. The patient has severe lumbar stenosis with neurogenic claudication. Decompression is well supported by the referenced literature to reduce pain and increase function. The current medical evidence supports the requested services in this patientas case. Therefore, the requested lumbar spine surgery (laminectomy, facetectomy and foraminotomy, single vertebral segment) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 56-year-old female enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees low back pain. The physician reviewer found the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is medical literature supporting the utility of radiofrequency neurolysis in this clinical setting. In addition, the patient was previously treated with radiofrequency ablation which provided pain relief which lasted almost 11 months. As such, the request for radiofrequency neurolysis is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a five-year old male who has been diagnosed with autism spectrum disorder. . The patientas parent has requested reimbursement and prospective authorization and coverage for applied behavior analysis (43.5 hours per week of code 97135 and 18 hours per month of code 97155) provided from 10/06/20 through 4/06/21. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. Based on the submitted documentation, 40 hours per week of 97135 are medically necessary and 16 hours per month of code 97155 are medically necessary. Per the records, the patient is actively working on goals. In an undated letter, the patientas provider requested 40 hours of one-to-one applied behavior analysis, which is well within current treatment guidelines. Behavior Analyst Certification Board guidelines note, aTreatment hours are subsequently increased or decreased based on the clientas response to treatment and current needs. Hours may be increased to more efficiently reach treatment goals. Decreases in hours of therapy per week typically occur when a client has met a majority of the treatment goals and is moving toward discharge.a As this patient is actively work on goals, is making progress, and is not yet ready for discharge, 40 hours per week of code 97135 is appropriate. Additionally, the request for 40 hours of code 97135 per week meets the medical necessity criteria set by Papatola and Lustig. Their definition includes ahealth-care services that a provider, exercising a prudent clinical judgment, would provide to a patient for the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms and are (a) required to meet the essential health needs of the patient; (b) consistent with the diagnosis of the condition for which they are required; (c) consistent in type, frequency, and duration of treatment with scientifically based guidelines as determined by medical research; (d) required for purposes other than the convenience of the provider or the comfort of the patient; and (e) rendered in the least intensive setting that is appropriate for the delivery of health care.a Applied behavior analysis is the most effective treatment for autism, thus is essential to meet the patientas needs. Similarly, applied behavior analysis is consistent with the diagnosis of autism. With regard to code 97155, 16 hours per month is medically appropriate, as this is 10% of the one-to-one applied behavior analysis which will be provided. Therefore, 40 hours per week of code 97135 and 16 hours per month of code 97155 from 10/06/20 through 4/06/21 were and are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 52-year-old female enrollee has requested authorization and coverage for matrix-assisted autologous chondrocyte implantation (MACI) procedure. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that the records document a history of progressively worsening bilateral knee pain. Functional difficulty is reported in activities of daily living and recreational pursuits. She is status post bilateral knee arthroscopy, chondroplasty, synovectomy, and plica resection, and chondral biopsy on the right knee on 7/18/18. The surgeon reports right knee operative findings including a full thickness grade III/IV chondral defect on the lateral facet of the patella measuring 2.5 x 2.5 cm, and a full thickness grade III defect on the trochlea measuring 1.5 x 1.5 cm. The left knee had similar findings with grade IV chondral defect in the lateral facet of the patella measuring 2 x 2 cm, and a grade III defect on the anterolateral trochlea measuring 5 x 5 mm. All defects had been debrided back to stable margins with Outerbridge grade I/II at the lesion borders. Detailed evidence of recent nonoperative treatment protocol trial and failure has been submitted. There is U.S. Food and Drug Administration (FDA) approval for the use of MACI in this clinical scenario. There is current peer-reviewed evidence indicating that MACI is safe and effective for treatment of full thickness cartilage defects in the knee, with no effect of the location of the defects or number of defects on study outcomes. Therefore, the requested MACI procedure is likely to be superior over other treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A year-old female enrollee has requested reimbursement for collagen crosslink testing provided on 4/17/19. 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 the use of bone turnover markers is standard practice among endocrinologists and other specialists in osteoporosis. It is used as a guide to monitor compliance and efficacy of treatment. It also helps to identify non-responders that require additional work-up for other causes of osteoporosis. In this case, the patients provider planned to use the information from this test result to determine whether the patient may resume therapy for osteoporosis and subsequently to monitor therapy. Naylor and colleagues noted that measurement of bone turnover markers after withdrawal of bisphosphonates is potentially useful to evaluate patients that are taking a pause from treatment. Thus, collagen crosslink testing provided on 4/17/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 42-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational for treatment of the enrollees glioblastoma multiforme.   The physician reviewer found the patient is a 42-year-old female who initially underwent surgical resection for a glioblastoma. She went on to receive chemotherapy and radiation therapy and has started treatment with tumor treatment fields (TTF) with Optune. The patient has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational. TTF with the Optune device is supported in the peer-reviewed medical literature for patients in the treatment of glioblastoma. One phase three study that examined the outcomes of patients with and without TTF found an improvement in survival (Stupp, et al). Moreover, TTF has not been associated with any major side effects. As a result, national guidelines from the National Comprehensive Cancer Network (NCCN) endorse the use of this device. Therefore, Optune device with transducer arrays provided from 3/8/17 forward was and is likely to be more beneficial for the treatment of the patients condition than standard therapy. Based upon the information set forth above, the equipment at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 42-year-old female enrollee has requested reimbursement for DecisionDx Melanoma testing (84999) performed on 1/23/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although DecisionDx Melanoma may be an independent predictor of metastasis risk, there is a lack of peer-reviewed published studies confirming this hypothesis. For this reason, the DecisionDx Melanoma testing (CPT code 84999) performed on 1/23/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 48-year-old female enrollee has requested authorization and coverage for a Cochlear Baha Attract System.  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 that The Cochlear Baha Attract System has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although the Cochlear Baha Attract System is approved by the U.S. Food and Drug Administration, in this patients case it is not likely to be more beneficial than the traditional Baha Connect System. Based on the medical literature and clinical documentation submitted for review, the requested services 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 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 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is support for a portion of the services at issue. This patient has painful varicose veins bilaterally. She is status post radiofrequency ablation of left great saphenous vein and ultrasound-guided foam sclerotherapy. There is support for the requested services for the left leg. For the left leg, the veins are residual after a prior thermal ablation. She continues to be symptomatic. Thus, the requested services for the left leg are likely to be superior over other treatment options. With regards to the right leg, the varicose veins are de novo. There is no saphenofemoral junction or saphenopopliteal junction reflux. Per the medical evidence, endovenous thermal ablation is preferred to surgery and foam sclerotherapy in the treatment of small saphenous vein incompetence. In sum, the requested foam sclerosant/endovenous ablation of the left leg is likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 34-year-old female enrollee has requested authorization and coverage for an MRI of the abdomen. 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 this patient has a genetic mutation, PRSS1, which is associated with hereditary pancreatitis, a markedly elevated risk of pancreatic cancer. It is also associated with risk of chronic pancreatitis, which causes the diarrhea and bloating symptoms, which the patient presented with. Given the increased risk of pancreatic cancer at a young age in patients with PRSS1 mutations, American Gastroenterological Association Institute guidelines for screening in patients with genetic predisposition for pancreatic cancer state that screening should be initiated at age 40. However, there is a significant rate of pancreatic cancer at young ages (8% before age 50), some of which could be missed by strict adherence to these guidelines. Separately, the patient is at risk for elevated chronic pancreatitis, and has symptoms consistent with this. Identification of chronic pancreatitis early may delay or prevent morbidity. MRI is reported to be a better diagnostic test than computed tomography scan for diagnosis, and endoscopic ultrasound is associated with higher procedural risk than magnetic resonance imaging, especially in the setting of Ehlers-Danlos syndrome. Therefore, the requested MRI of the abdomen is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 56-year-old female with a history of muscle and joint pain. The patient was treated 
with several medications to combat the muscle and joint pain and was referred to a chiropractor, 
without significant benefit. The patient underwent a removal of intact breast implant on 4/7/22. 
The Health Insurer has denied the services at issue as not medically necessary for the treatment of 
the patients medical condition. This denial is the subject of this appeal and determination. The 
physician reviewer found that according to Wee and colleagues, while some studies have observed 
overall symptomatic improvement after breast implant removal, There is a lack of studies 
evaluating changes in specific symptoms over time. In this case, the patient has a history of severe 
back, neck, torso, chest, and joint pain due to her breasts. The records provided for review suggest 
that the patients muscle and joint pain were due to the size of the breast implant rather than breast 
implant illness (BII). Loss of range of motion is not associated with BII but is instead most likely 
secondary to a large implant. The patients symptoms overall are secondary to complications of 
implant size and that of a cosmetic procedure. Early capsular contracture would not result in 
limited range of motion and diffuse symptoms. Given these findings, the removal of intact breast 
implant performed on 4/7/22 was not medically necessary for the treatment of this patient.