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

Summary Reviewer 2 
A 28-year-old female insured has requested authorization and coverage for intravenous (IV) 
Gammagard. The Health Insurer has denied this request indicating that the requested treatment is 
considered investigational for the treatment of the insured's refractory relapsing polychondritis.  
The physician reviewer found that the treatment of relapsing polychondritis is challenging and 
often  lifelong.  Corticosteroids  remain  the  mainstay  of  therapy  options,  but  other 
immunosuppressive agents and biologic agents may be used in combination or as alternatives if 
corticosteroids are inefficacious (Mathian, et al.). The choice of alternative therapy depends on the 
severity and location of the inflammation, as well as the patient's overall health and response to 
previous treatments. The current medical literature has suggested IVIG as an alternative treatment 
option for patients with relapsing polychondritis (Lekpa and Chevalier). IVIG is a preparation of 
antibodies derived from human plasma which has been shown to have immunomodulatory and 
anti-inflammatory effects. IVIG is typically administered every two to four weeks and is generally 
well-tolerated, though the dose and frequency may be adjusted based on the patient's response. In 
this case, the records available for review indicate that the patient has tried and failed treatment 
with  several  standard  therapies,  including  multiple  courses  of  high-dose  corticosteroids, 
methotrexate,  dapsone,  adalimumab,  infliximab,  cyclosporine,  abatacept,  rituximab,  and 
azathioprine. The patient has experienced documented success with IVIG as a treatment modality. 
Therefore, the requested IV Gammagard is likely to be more beneficial for the treatment of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 51-year-old male with heartburn, vomiting, dyspepsia but was taking no acid suppression medication at the time of his 2/20/15 visit to his provider. Evaluation has included esophageal manometry with impedance testing that suggested a hiatal hernia but showed no classic dysmotilities. An esophagogastroduodenoscopy (EGD) with biopsies supported mild reactive changes at the gastroesophageal junction, H. pylori-negative mild reactive gastropathy, and peptic duodenitis. A 24-hour pH test identified both acid and non-acid reflux events with good symptom correlation with heartburn, regurgitation, and vomiting episodes. The patient has requested authorization and coverage for the LINX device. The Health Insurer has denied this request indicating that the requested procedure is considered investigational. The LINX device received U.S. Food and Drug Administration (FDA) approval for patients with diagnosed GERD as defined by abnormal pH testing, and who continue to have chronic GERD symptoms despite maximal medica_l therapy for the treatment of reflux. The FDA noted that appropriate patient selection is important and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative work-up for antireflux surgery. This patient has already undergone much of this pre-operative assessment which revealed relatively mild GERD, predominantly recumbent. However, the available records do not support ongoing use of acid suppression therapy, and as such is not considered medically refractory to acid blocker drugs. Accordingly, the requested LINX device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested 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: Overturned

Summary Reviewer 


A 25-year-old male enrollee has requested authorization and coverage for Daklinza 60 mg and Sovaldi 400 mg for 12 weeks.  The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, the guidelines recommend therapy with Sovaldi and Daklinza for 12 weeks.  All told, the requested Daklinza 60 mg and Sovaldi 400 mg for 12 weeks are medically indicated for the treatment of this patient.  Therefore, the requested medications are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 43-year-old female enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found that minimally invasive SI joint fusion has not been demonstrated to result in superior health outcomes for the treatment of back pain when compared to standard available treatment options. Further, this patients medical records do not show any evidence of SI joint instability, fracture, or tumor, thus the criteria for SI joint fusion are not met. This patient has chronic back pain after previous lumbar fusion surgery. The pain is likely degenerative in cause. For these reasons, the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 63-year-old male enrollee has requested authorization and coverage for Repatha SureClick. 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 an intermediate 10-year cardiovascular risk of approximately 8.4%. He also has other risk factors which increase his cardiovascular risk independent of those measured by the clinical cardiovascular calculator, including a family history of cardiovascular disease and a markedly elevated coronary calcium score. He is a candidate for statin therapy based on published guidelines. He has done lifestyle modification but has a documented intolerance to two statin medications. He was started on ezetimibe per guidelines. The patient had a moderate reduction in his LDL to 125, but this is still not at goal. In a patient with elevated risk and intolerance to multiple statin medications who is already on ezetimibe and is still not at LDL goal, the addition of the proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitor Repatha SureClick is reasonable and medically indicated to achieve the guideline directed LDL goal. Therefore, Repatha SureClick is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 47-year-old female enrollee has requested reimbursement for proton beam therapy provided on 5/20/19 through 7/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that compared to standard radiotherapy with photon-based intensity modulated radiation therapy, the benefit of proton therapy is that with its Bragg Peak, radiation dose is deposited more precisely on its target. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Comparing dosimetric parameters, proton therapy will always appear superior to photon-based intensity modulated radiation therapy. However, this dosimetric benefit does not always translate into an actual clinical benefit to the patient. While there are several dosimetric studies evaluating proton therapy for rectal cancer, there is a lack of studies evaluating clinical benefit. In this case, the treating provider submitted a comparison dose-volume histogram of intensity modulated proton therapy versus photon therapy. However, the photon therapy was a three-dimensional conformal plan and not an intensity modulated radiation therapy plan. Thus, a true comparison of the benefit of protons versus photons cannot be made. In sum, proton beam therapy provided from 5/20/19 through 7/12/19 was not likely to have been more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 57-year-old male who presented to his provider on 1/20/22. The patient has 
requested authorization and coverage for MRI cervical spine without contrast material. The 
physician reviewer found that at issue is whether the requested MRI cervical spine without 
contrast  material  is  medically  necessary  for the  evaluation  of  this  patient.  The  submitted 
documentation supports the medical necessity of the requested service. Kothari explains that 
cervical radiculopathy is a clinical diagnosis that may result from a number of causes including 
but not limited to degenerative disease, infection, inflammation, and tumor. Ancillary testing is 
important in localization and in determining pathology in addition to the clinical evaluation. 
Neuroimaging is indicated for most patients with a corresponding neurological deficit present on 
examination  and  is  currently  the  study  of  choice  to  assist  in  confirming  a  compressive 
radiculopathy for diagnostic and treatment purposes. In this case, the patient has symptoms 
suggestive of left cervical radiculopathy with numbness on physical examination in the vicinity of 
the left C3 dermatome. In this clinical setting, an MRI of the cervical spine without contrast 
medically indicated for the evaluation of suspected left C3-C4 radiculopathy. Therefore, MRI 
cervical spine without contrast material is medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 32-year-old male enrollee has requested reimbursement for laboratory testing performed on 12/05/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient was appropriately treated for infectious risks associated with monkey bites. The standard references for management of travel-associated illness do not discuss risk of transmission of hepatitis from monkey bites. The medical literature does not indicate that monkey bites are a source of transmission for hepatitis viruses. The testing ordered after his return to the United States was not medically indicated. Therefore, laboratory testing performed on 12/05/18 was not medically necessary for the evaluation for the patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


An 18-year-old male has requested reimbursement for Anser IFX testing performed on 7/09/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the current medical evidence has not demonstrated the superior efficacy of the services at issue.  The use of Anser IFX testing to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with Crohns disease.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there were a lack of standard guidelines defining a therapeutic strategy at the time of testing.  A systematic review by Yarur and colleagues noted that future prospective controlled studies are needed, especially considering that anti-tumor necrosis levels are influenced by several variables that can fluctuate over time and among individuals.  In sum, Anser IFX testing performed on 7/09/15 was not likely to have been of greater benefit than 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 38-year-old female enrollee has requested authorization and coverage for Humira 40 mg weekly.  The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees ulcerative colitis. The physician reviewer found that there is sufficient support for the requested medication dosage in this clinical setting. This patient has had uncontrolled disease on dosing every 14 days. In the ULTRA 2 trial by Sandborn and colleagues, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks. The trial advanced non-responders at week 8 to weekly therapy as well as week-8 responders. Both groups contained a fraction that responded to dosing frequency increase. Current guidelines recommend that when anti-tumor necrosis factor level is low, and anti-drug antibody is low or absent (as in this case), the drug dose should be increased. Staying on the dose of 40 mg every other week or changing to a different medication may result in disease flare, disease complications, and hospitalization. For these reasons, the request for Humira 40 mg weekly is likely to be of greater benefit than other available treatment options. Based upon the information set forth above, the requested medication dosage is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 35-year-old female enrollee has requested reimbursement for colorectal cancer screening 
using chromoendoscopy or narrowband imaging optical colonoscopy performed on 1/25/22. 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 
Chromoendoscopy is a well-accepted adjunct to colonoscopy to look for dysplasia in patients 
with  longstanding  ulcerative  colitis.  Patients  undergo  a  standard  colonoscopy.  During  the 
examination, the mucosa is inspected and biopsied in standard fashion. Subsequent to this, the 
mucosa is sprayed with a vital dye that highlights subtle areas that may represent neoplasia. 
These areas are biopsied separately. Chromoendoscopy has become the standard of care for 
patients previously identified to have abnormal mucosa on a previous colonoscopy, such as this 
patient. The medical evidence supports the services at issue in this setting. Therefore, colorectal 
cancer  screening  using  chromoendoscopy  or  narrowband  imaging  optical  colonoscopy 
performed on 1/25/22 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 62-year-old female enrollee has requested reimbursement for acute hospital admission to telemetry level of care from 9/24/18 through 9/25/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of chest pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records document some coronary risk, chest pain concerning for possible ischemia, a normal cardiovascular physical examination, an unchanged electrocardiogram and an initial negative evaluation in the emergency department. In this circumstance, it would have been reasonable to anticipate a hospital length of stay to require less than 48 hours or less than two midnights, and it would have been safe to manage the patient at an observational level of care as opposed to an inpatient admission. There was no documented hemodynamic instability or objective evidence of coronary ischemia or other acute medical condition to warrant an inpatient admission. Thus, acute hospital admission to telemetry level of care from 9/24/18 through 9/25/18 was not medically necessary for the treatment of this patient. Therefore, the services at issue were 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 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that standard medical therapies for 
temporomandibular joint disorder include NSAIDs, both enteral and topical, diet restriction, jaw 
exercises including physical therapy, warm and cold compresses, and splinting with a dentist 
prescribed occlusal devise. Gonzalez-Perez and colleagues note that the use of dry needling is 
also becoming more common and has been shown to be safe and effective in the treatment of 
temporomandibular joint disorder. As the use of Botox for the treatment of temporomandibular 
joint disorder is not FDA approved, there is limited high quality data regarding its use and efficacy 
for the treatment of temporomandibular joint disorder, and there is no standardization for its 
administration in this clinical setting. In a randomized controlled trial comparing the efficacy of 
dry needling and Botox in the treatment of temporomandibular joint disorder,  Kutuc and 
colleagues reported that at the end of six weeks, patients treated with dry needling reported 
more pain relief on the visual analog scale (VAS), better improvement in jaw protrusion angles 
on both sides, and better recovery of temporomandibular joint function than the patients treated 
with Botox. In a randomized controlled trial comparing the efficacy of Botox to occlusal splinting 
in the treatment of myofacial pain, Miotto and colleagues noted improvement in both treatment 
arms  but  did  not  specify  any  statistically  significant  difference  between  the  groups.  In  a 
systematic review of the use of Botox in the treatment of temporomandibular joint disorder that 
included an investigation of physical therapy versus Botox, Patel and colleagues found no 
statistically significant difference between either treatment modality. Given the lack of evidence 
supporting the use of Botox over other proven treatment modalities, while Botox is emerging as 
a promising therapeutic option in the management of certain aspects of temporomandibular 
joint disorder, the requested service is not likely to be more beneficial than other currently 
available standard treatments for the treatment of this patient. Therefore, Botox is not likely to 
be more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is an 11-year-old male who has been diagnosed with autism spectrum disorder and attention deficit/hyperactivity disorder (ADHD). The patientas parent has requested reimbursement for speech therapy provided from 3/13/19 through 6/12/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records indicate that the patient was performing at a range from the average to very superior range in the speech areas of concern, including articulation and pragmatic speech. No short-term speech therapy goals were indicated. The American Speech-Hearing Association lists as one of its criteria for discharge from therapy awhen the communication disorder has been remediated or compensatory strategies have been successfully established.a One of the major areas of language difficulty in children with autism spectrum disorder is pragmatic language. This patient was noted to score in the 97th percentile on the TOPL-2, which was in the superior range. He did not appear to require speech therapy to address deficits in pragmatic language. His pediatrician wrote a referral for speech therapy to address stuttering, but there is no comment regarding stuttering being an issue in his speech therapy reports. Therefore, speech therapy provided from 3/13/19 through 6/12/19 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a six-year-old male enrollee has requested authorization and coverage for growth hormone therapy. 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. The records document linear growth around the fifth percentile. There is a lack of evidence of poor growth based on the growth chart. Growth hormone therapy is not indicated for a child that is growing well. The clinical notes indicate that this patients weight is at the first percentile. Poor nutrition can affect growth, and this patient may benefit from extra calories to improve growth. This patient has a relatively short genetic potential. However, growth hormone therapy is not indicated to treat short genetic potential. There is no indication of idiopathic short stature, as this patient is not growing below -2.25 standard deviations for age and sex. Thus, growth hormone therapy is not medically necessary for the treatment of this patient.