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

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for residential treatment provided from 9/11/19 through 9/15/19. 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 Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4 due to signs of consistent deficits in ability to care for self, as evidenced by the patients continued restriction of food intake, leading to lack of desired weight gain. With regard to functional impairment, the records support a score of 3. The patient had moderate functional impairment. In terms of comorbidity, the records support a score of 4. The patient failed to achieve full weight restoration and she had primary amenorrhea. With regard to level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful recovery environment, due to conflict with her parents regarding her eating, as well as the disruptions to her social and educational activities caused by her need for intensive treatment. In terms of level of support of the recovery environment, the records support a score of 2 due to the parents active participation in treatment. With regard to resiliency and treatment history, the records support a score of 4 due to persistence of disordered eating despite extensive prior treatment exposure at various levels of care. In terms of treatment acceptant and engagement of the patient, the records support a score of 3. The patient was incompletely engaged, due to her minimization of the seriousness of her disordered eating and her struggles to comply with her food plan. Therefore, the records support a total score of 22. Due to serious risk of harm, the recommended level of care is level five medically monitored residence-based services. Therefore, residential treatment provided from 9/11/19 through 9/15/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center services provided from 7/12/16 forward. 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 behavioral health condition. The physician reviewer found the psychiatric residential treatment center services provided from 7/12/16 forward were and are medically necessary for treatment of the patients medical condition. In this case, the patient presents with impulsivity, poor decision making and anger outbursts which make him volatile and a potential danger to others. In addition, his behavior is of a nature that his family is unsafe around him. The documentation submitted for review demonstrates that multiple facetime family sessions did not go well. The patient was described as being agitated and frustrated and argumentative. On 8/19/16, the individual therapy note documents that he had been argumentative consistently throughout the day. He angrily teased a peer several times and aggressively argued with staff and peers. The patient lacks the coping skills needed for limit setting and disappointment. Given the above, residential treatment center services have been established as medically necessary for treatment of the patients behavioral health condition. Moreover, the treatment at issue is reasonably expected to improve the patients condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
 
A 51-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 1/18/21. 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 Melanoma is a cancer that is curable in its earliest stages. Cutaneous 
melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for 
those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be 
amenable to excision but this suggests a high risk for the development of metastatic disease in 
the future. Such patients may be observed or treated with interferon-alpha. The data on 
DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node 
biopsy. There has also been some lack of consistency between various genes being used as 
biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the 
treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma 
testing performed on 1/18/21 was not likely to have been more beneficial than other available 
methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 56-year-old male enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatment provided on 8/2/16, 8/4/16, and 8/9/16. 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 that there is sufficient support for the services at issue in this clinical setting. TMS is a novel, non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population.  A typical treatment course of TMS consists of 30-40 sessions spanning four to six weeks.  Tapering of the therapy is clinically recommended. Per Perera and colleagues, Once a determination of maximum benefit is made, the TMS treatments should be tapered  for the patient. A typical taper occurs over the course of two through three weeks and may consist of as many as six sessions. Thus, the services in dispute were reasonably expected to both improve the patients condition and consolidate the efficacy of the therapy.  The duration of service and number of sessions were consistent with community practice standards, in this patients case. The therapy itself was safe and appropriate for the treatment of this patients behavioral health condition. All told, TMS treatments provided on 8/2/16, 8/4/16 and 8/9/16 were medically necessary. Therefore, for the reasons stated above, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the International Society for Advancement of Spine Surgery (ISASS) policy statement for minimally invasive sacroiliac joint fusion provides specific indications for surgery. In addition to such specific criteria, it is noted, aAdditional or alternative diagnoses that could be responsible for the patientas ongoing pain or disability have been clearly considered, investigated and ruled out.a In this patientas case, there are potential alternate and/or additional contributing diagnoses. The three clinical reports are significantly varied regarding subjective and objective findings documented.  For example, on 9/18/20, the documented findings suggested multiple alternate pain generators, plausibly inclusive of the thoracolumbosacral regions of the spine itself.  There were multiple denoted subjective and examination findings in the 9/18/20 report that were not significantly discussed and/or completely ruled out as significant plausible pain generators in the subsequent clinical reports. The medical literature at large does not exclusively rely on injection results as being 100% diagnostic of sacroiliac joint(s) as the clear pain generator, in isolation. Nor are the denoted sacroiliac joint injection results dispositive for a definitive surgical indication, again when considered within the realm of the entirety of records reviewed. Furthermore, multiple other plausible pain generators including at the lumbosacral spine are evident. Therefore, the requested minimally invasive sacroiliac joint fusion is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 10-month-old female enrollee has requested reimbursement for a cranial remolding orthosis provided on 7/19/17. The Health Insurer has denied this request indicating that the device at issue was not medically necessary for treatment of the enrollees severe brachycephaly. The physician reviewer found that since the back to sleep approach was recommended by the American Academy of Pediatrics in 1994, there has been an increase in the incidence of positional plagiocephaly in infants (Trachtenberg, et al). One review of 15 studies on the treatment of positional plagiocephaly in infants and concluded that there is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy (Tamber, et al). The authors also noted that in general, infants with a more severe presenting deformity and infants who are helmeted early in infancy tend to have more significant correction (and even normalization) of head shape. Roby and colleagues evaluated 1045 teenagers born after the introduction of the back to sleep recommendation and found persistent plagiocephaly in only 1.1% and brachycephaly in 1%, compared with the estimates of 20-48% incidence in infants, suggesting that positional plagiocephaly may self-correct over time. Given that the Congress of Neurological Surgeons recommends cranial orthosis treatment for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment, the DOC Band device at issue was indicated for treatment of this patients medical condition (Tamber, et al). A trial of repositioning had occurred, and she was documented as having severe brachycephaly with a cephalic index of 101.5, which was more than six standard deviations from the mean. Thus, the cranial remolding orthosis provided on 7/19/17 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the device at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 62-year-old male enrollee has requested authorization and coverage for sacroiliac joint (SI) fusion/percutaneous spine fusion. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees SI joint disorder. The physician reviewer found that the submitted documentation fails to demonstrate the efficacy of the sacroiliac fusion, over any standard therapy. The case specific reasons reference a documented clinical syndrome of complex regional pain syndrome with multiple pain generators contributing to the patient's experience of chronic pain. The patient has had an L4-S1 fusion and has had procedures above the levels of fusion but those procedures do not rule out the likelihood of continuing chronic pain from adjacent segment disorder above the levels of fusion. The issue of pain originating at the sacroiliac joint remains controversial, both in general and in patients such as this patient. In the study by Rupert and colleagues, it is pointed out that there are no definitive historical, physical or radiological features that can definitely establish a diagnosis of sacroiliac joint pain. In this specific patient, local anesthetic injection sometimes used in an effort to localize the sacroiliac joint as a pain generator gave only a short-term relief of symptoms. The reliance of local anesthetic injection in the sacroiliac joint to establish that joint as the prime pain generator is susceptible to placebo effect. The statement of a positive benefit from local steroid injection to the sacroiliac joint is not sufficient to provide evidence for likely benefit through the proposed sacroiliac fusion. In summary, it is not likely to be beneficial for this patient to undergo sacroiliac fusion for treatment of his chronic pain.  For the reasons set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 13-year-old female enrollee has requested reimbursement for the neurological evaluation and testing performed from 3/17/17 to 5/24/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees delays in gross motor, fine motor, language, and daily functioning skills. The physician reviewer found that based on the available documentation, the neuropsychological testing provided from 3/17/17 through 5/24/17 was not medically necessary for evaluation of this patients medical condition. The patient has previously been diagnosed with global developmental delay, microcephaly and ADHD combined subtype. She has been noted to have learning difficulties on previous educational psychological testing performed through the school district. The neuropsychological testing addressed her learning difficulties and ADHD, and predominantly educational difficulties rather than a medical condition. In the medical literature, Palumbo and Lynch described the utility of neuropsychological testing in addressing learning disabilities in adolescents. Pham and Riviere outlined how neuropsychological testing in children with ADHD allows implementation of assistance in an educational setting. All told, the documentation does not support the medical necessity of the neurological evaluation and testing performed from 3/17/17 to 5/24/17 for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 35-year-old male with a lengthy history of mood/psychotic episodes and amphetamine use disorder. He was admitted to the residential treatment center due to symptoms of hallucinations, thought disorganization, racing thoughts, and pressured speech. The physician reviewer found that the American Association of Community Psychiatrists Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) is a beneficial tool in determining the appropriate level of care. In terms of risk of harm, the records support a score of 3, due to the evidence of self-neglect and inability to care for himself even in the structured residential treatment center environment due to his manic symptoms. He had a history of dangerous actions due to his manic symptoms. With regard to functional status, the records support a score of 4. This patient has been unable to complete community college courses or hold a job for longer than one month. In terms of comorbidity, the records support a score of 4 due to the presence of disabling psychiatric symptoms that interact with and impair his ability to recover from his substance use disorders. With regard to level of stress of the recovery, the records support a score of 4. He is technically homeless but mandated by probation to live in a recovery house. He has historically been unable to remain in recovery houses longer than days to weeks due to relapse of manic and psychotic symptoms. In terms of level of support of the recovery environment, the records support a score of 3.  His only natural supports would be his parents, and the patient does not reliably include them. He has not had cohesive professional supports outside of the residential treatment center. With regard to acceptance and engagement, the records support a score of 4. He has had significant treatment exposure but has been unable to achieve complete remission of optimal control of symptoms even with repeated exposure. Attempts to maintain gains attained in intensive treatment have had limited success. Therefore, the patient has a composite score of 22. In this case, the patients functional status and comorbidity were both scored as 4, which would support the residential treatment center placement. Thus, psychiatric residential center treatment provided from 12/30/19 through 1/17/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found the most important considerations in the use of bronchial thermoplasty are the proper selection of patients and ensuring an experienced qualified provider is performing the procedure. Bronchial thermoplasty has adequate data on long-term safety and effectiveness in patients with asthma in terms of demonstrating improvement in symptoms and reduction in exacerbations. On the basis of daily symptoms, frequent rescue medication use, interference with daily activities and frequent exacerbations, this patient meets criteria for severe persistent asthma. However, there is not adequate information provided to determine two important considerations in the treatment of asthma. First, the records do not document that alternate diagnoses have been ruled out. The appearance of infiltrates and adenopathy on the computed tomography (CT) may indicate a secondary cause of wheezing. Secondly, there was not information provided to exclude other asthma therapies such as omalizumab or mepolizumab based on IgE levels or eosinophil counts. All told, there is a lack of documentation supporting the requested bronchial thermoplasty as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested authorization and coverage for functional electrical stimulation RT300 therapy system.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees incomplete paraplegia. The physician reviewer found the requested device is likely to be more effective than other options for treating this patient.  There have been a number of studies reporting the benefits and utility of functional electrical stimulation cycling in patients with spinal cord injury.  The study by Johnson and colleagues demonstrated that cycling with functional electrical stimulation led to gains in oxygen uptake when compared to passive cycling alone.  Per the submitted documentation, the patient has demonstrated good response to initial trials with the requested device.  Based on the literature, his clinical history, and his response to a trial evaluation, the requested functional electrical stimulation RT300 therapy system is likely to be more effective than other treatment modalities.  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: Upheld

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 had an early stage melanoma followed by a node positive recurrence. DecisionDx-Melanoma testing was performed on the recurrent tumor. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. The role of DecisionDx-Melanoma testing for recurrent node positive disease has not been established. In sum, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 65-year-old male enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL auto-injector. 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 this patient has multiple risk factors for coronary artery disease and a strong family history of coronary artery disease. His 10-year risk of symptomatic cardiovascular disease is 15%, placing him in the intermediate risk category. In addition, he has known moderate coronary artery disease on cardiac catheterization, particularly calcified ostial disease of the right coronary artery. He requires aggressive risk factor modification and is making lifestyle changes. In addition, he has a history of intolerance to multiple statin medications. The patient has known established coronary artery disease and elevated 10-year risk of symptomatic disease, which could be brought down significantly with optimal risk factor management. The current evidence supports proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors in this clinical setting. Therefore, Repatha SureClick 140 mg/mL auto-injector is medically necessary for the treatment of this patient.