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

Summary Reviewer 1

A 24-year-old female enrollee has requested reimbursement for 83993 (fecal calprotectin) provided on 1/30/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who has a history of diarrhea. The physician reviewer found that Calprotectin is a zinc and calcium binding protein that is derived mostly from neutrophils and monocytes. It can be detected in stool, making it a valuable marker of neutrophil activity. Fecal calprotectin levels are increased in intestinal inflammation and may be useful for distinguishing inflammatory from noninflammatory causes of chronic diarrhea. Fecal calprotectin can be considered as an adjunctive test in diagnostic evaluation of patients with chronic diarrhea. Therefore, for 83993 (fecal calprotectin) provided on 1/30/18 was likely to have been superior over other methods of evaluating this patient. 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: Experimental
Decision: Upheld

Summary Reviewer 1


A 57-year-old male 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 severe, persistent asthma. The physician reviewer found that in the peer-reviewed medical literature, Torrego and colleagues found that bronchial thermoplasty for patients with moderate to severe asthma provides a modest clinical benefit in quality of life and lower rates of asthma exacerbation, but no significant difference in asthma control scores. Weschler and colleagues noted that the long-term safety and effectiveness in patients with severe persistent asthma showed at five years durability of benefits of bronchial thermoplasty in regards to asthma control and safety persisted. However, in this case, the record fails to demonstrate any recent severe exacerbations or emergency department visits. The most recent notes state that the patients disease is stable. All told, the requested bronchial thermoplasty 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 52-year-old female enrollee has requested reimbursement for gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18. 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 the 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. Thus, gene testing (unlisted multianalyte assay with algorithmic analysis) performed on 12/21/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 




A 49-year-old female enrollee has requested authorization and coverage for the Flexitouch pneumatic compression pump. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees lymphedema swelling status post mastectomy. The physician reviewer found that the Flexitouch pneumatic compression system is not medically necessary for diagnosis and treatment of this patients medical condition. A review of the literature reveals that there is insufficient evidence to recommend the Flexitouch pneumatic compression system over conventional lymphedema pumps. Wilburn and colleagues compared the Flexitouch with conventional maintenance therapy and revealed that further investigation was needed. Ridner and colleagues reported that the positive results suggest that further investigation will be useful. Fife and colleagues compared treatment with the Flexitouch system with the Biocompression Systems Sequential Circulator. The authors reported statistically significant between-group differences in two of these both favoring treatment with the Flexitouch system. However, the study by Fife and colleagues was limited by its small sample size, missing data on the local tissue water outcome, and unclear blinding of outcome assessment. Additionally, the outcomes reported were primarily volume of fluid removed, which is an intermediate outcome. Pilch and colleagues compared lymphedema pumps in terms of number of chambers and cycle times and noted that overall there was not a significant difference among groups. Without sufficient evidence in the literature for the requested device and without evidence of failed conservative management, the requested Flexitouch pneumatic compression pump is not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested device is 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 66-year-old female enrollee has requested authorization and coverage for Embeda. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees neuropathic pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Nucynta has a drug interaction with Cymbalta which can cause serotonin syndrome. She has tried morphine and oxycodone previously, without benefit. It is not medically reasonable to try a medication that she has previously failed. Since she is stable on Embeda, it is medically appropriate to continue on this medication. The use of strong opioids for neuropathic pain is supported by clinical practice guidelines. Thus, Embeda is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 33-year-old female enrollee has requested reimbursement for homocysteine testing, Factor V Leiden genetic testing and methylenetetrahydrofolate reductase (MTHFR) performed on 8/7/15. The Health Insurer has denied this request indicating that the services at were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) practice bulletin for inherited thrombophilias in pregnancy indicate that testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence. Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin (LMWH) prevents recurrence in these patients. In addition, there is insufficient evidence of an association and, therefore, insufficient evidence to either screen for or treat women with inherited thrombophilias and obstetric histories that include complications such as fetal growth restriction or preeclampsia. Moreover, there is a lack of medical literature supporting an association between the Factor V Leiden mutation and heritable thrombophilias and either pregnancy loss or obstetric complications characterized by placental insufficiency. Therefore, homocysteine testing, Factor V Leiden genetic testing and MTHFR performed on 8/7/15 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 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 


A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) provided from 1/22/16 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 overactive bladder.   The physician reviewer found the records document that this patient has a diagnosis of refractory overactive bladder. She has failed multiple second- and third-line therapies and is not a candidate for certain therapies including sacral neuromodulation as noted by the provider. She has responded to PTNS. Continued treatment with PTNS is medically necessary, and a nationally accepted standard of care for this patient. The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses. The recommended course of treatment is an initial series of 12 weekly office-based treatments followed by an individualized maintenance treatment schedule. Evidence from multiple randomized placebo-controlled trials supports the safety and clinical efficacy of PTNS. The available 12- to 36-month evidence appears consistent with maintained efficacy in relieving symptoms of overactive bladder (OAB) and urinary voiding dysfunction. The American Urological Association (AUA) and Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) guidelines support use of PTNS as third-line treatment in a carefully selected patient population with overactive bladder. Given that this patient has been treated with multiple second- and third-line therapies and is not a candidate for sacral neuromodulation, the PTNS provided from 1/22/16 forward was and is medically necessary for treatment of this patients refractory overactive bladder. Based on the foregoing discussion, 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is an 11-year-old female with short stature. The patientas parent has requested authorization and coverage for Nutropin AQ Nuspin. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. This patient was growing along the 5th percentile from age 4 years and was subsequently started on growth hormone therapy. She has a good IGF-1 generation on growth hormone treatment. This patient exhibited signs of growth failure before the growth hormone treatment was started. Per the submitted documentation, she had a good response to growth hormone therapy in terms of growth velocity. Continuation of growth hormone therapy is medically appropriate in this case. Therefore, Nutropin AQ Nuspin is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 26-year-old female enrollee has requested authorization and coverage for Xeljanz 5 mg The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees alopecia areata. The physician reviewer found that Alopecia areata is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Other autoimmune diseases are also linked with alopecia areata. Treatment is challenging and aims at the regrowth (reconstruction) of hair. Alopecia areata causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and self-confidence. Xeljanz (tofacitinib citrate) has been approved for the treatment of moderate to severe rheumatoid arthritis. It has been also studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the literature provide evidence for the effectiveness of this medication in the treatment of alopecia areata. Therefore, Xeljanz 5 mg is likely to be superior over other treatment options. Based upon the information set forth above, the requested medication 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 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. This patient has been taking Tymlos. In this clinical setting, a dual-energy x-ray absorptiometry (DEXA) is appropriate at the end of the two-year treatment to assess the patients response to therapy. The value of monitoring therapy with the use of biochemical markers of bone turnover to aid in clinical decision making is controversial. The test performed can be variable and subject to timing, dietary intake as well as lack of assay standardization. In sum, collagen crosslinks testing performed on 11/18/17 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: Upheld

Summary Reviewer 1

A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the criteria for sacroiliac joint fusion have not been met in this patients case. The patients records do not include documentation of failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest; physical therapy; or sacroiliac joint steroid injection must be reported. Moreover, there must be evidence that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Thus, although the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability, the patient has not adequately satisfied all of the ISASS criteria. All told, the requested sacroiliac 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 service 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 42-year-old male enrollee has requested authorization and coverage for the prescription medication Skyrizi 150 mg syringe. 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 according to the American Academy of Dermatology and the National Psoriasis Foundation, two leading authorities on psoriasis treatment, Skyrizi is a safe, effective and well-tolerated treatment of chronic plaque psoriasis. It is an immunoglobulin G (IgG) monoclonal antibody that neutralizes IL-17 and as such does not seem to have a significant effect on the pathogenesis of coronavirus infections. It is recommended as monotherapy for treatment of psoriasis. Methotrexate is an antimetabolite which can also work in treating psoriasis, but the efficacy and onset of action are not as good as compare with biologics.  Cyclosporine is only a short-term treatment for a chronic disease and would not be appropriate. Acitretin has inferior efficacy and risk profile to some of the biologic treatments. There is sufficient support for the requested medication in this clinical setting. Therefore, the prescription medication Skyrizi 150 mg syringe is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 49-year-old male with a history of chronic low back pain. On 7/30/20, the records noted that the patient has a displaced lumbar disc and left lumbar radiculitis. The physician reviewer found that the 2019 American Society of Interventional Pain Physicians (ASIPP) guidelines for use of sedation during routine pain management injections states, aGiven that patients undergoing pain procedures typically are anxious and in pain, mild to moderate sedation is acceptable for many patients.a The guidelines further state, aDeeper sedation should only be undertaken in the presence of anesthesia providers and for patients who have high anxiety, complex pharmacotherapy, or a low pain threshold when undergoing more painful interventional pain procedures. In special cases, the risk of patient movement during a procedure resulting in potential inadvertent injury may justify a deeper anesthetic state.a
The American Society of Anesthesiologists also published a statement regarding the use of sedation for pain management injections and concluded, aSignificant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services.a
In this case, the patient has a confirmed diagnosis of generalized anxiety disorder for which he is receiving medical treatment. The provider notes stated that the patient would undergo a lumbar epidural steroid injection but would require sedation because of a fear of needles. There is documentation from 2/16/18 showing that the patient suffered a severe case of vasovagal response during a lumbar medial branch block that was completed under local anesthetic only. He has a confirmed diagnosis of anxiety and known needle phobia which would make it difficult for him to undergo the epidural injection while remaining motionless. He also has a history of vasovagal response to previous injections done under local anesthetic only. Based on the medical records for review and current national guidelines, the request for monitored anesthesia care for the lumbar epidural steroid injection was medically indicated. Therefore, anesthesia for diagnostic or therapeutic nerve blocks and injections provided on 7/30/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 61-year-old male who underwent a colonoscopy for the indication of colorectal cancer screening on 3/22/21, with monitored anesthesia care. The patient has requested reimbursement for monitored anesthesia care provided on 3/22/21. The physician reviewer found according to the ASA guidelines for anesthesia care during endoscopic procedures, monitored anesthesia care is warranted in prolonged or painful procedures, such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that monitored anesthesia care is more likely necessary in patients with a failed history of moderate sedation for the procedure or psychological impediments to cooperation. The provided records do not support any of these criteria, or other criteria in the literature, such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA class III or higher, or morbid obesity. According to the most recent guidelines from the American Society for Gastrointestinal Endoscopy, during endoscopic procedures (unlike surgery) consciousness during the procedure is acceptable and is the goal during most procedures (which are performed with amoderate sedationa), and monitored anesthesia care is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA class IV or V, or risk for airway obstruction due to anatomic variant. For these reasons, the submitted records do not support the medical necessity of monitored anesthesia care over conscious sedation in this case. Therefore, monitored anesthesia care provided on 3/22/21 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  There is a lack of prospective controlled data to support random measurement of Remicade/Remicade antibody levels.  The concept of targeted drug level monitoring is supported for several classes of drugs.  However, evidence is lacking for biologic agents in the treatment of this patients condition.  There are multiple variables which drug level monitoring does not consider, thus making this line of testing suboptimal.  For example, the optimal trough level of Remicade remains unknown and likely varies from individual to individual based on unique pharmacokinetics.  Additionally, tissue levels of drug also play an important role.  Therefore, Anser IFX testing performed on 8/17/15 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.