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

Summary Reviewer 

A 46-year-old female enrollee has requested authorization and coverage for the Flexitouch pneumatic compression pump and leg garment. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the request for Flexitouch pneumatic compression pump and leg garment is not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not document that she has failed a sustained trial of compression or documentation that she has failed treatment with a compression pump. Given the lack of documentation of conservative treatments, the requested equipment is not indicated. Therefore, the medical necessity for Flexitouch pneumatic compression pump and leg garment has not been established in this clinical setting. Therefore, the requested equipment is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 31-year-old transgender female enrollee has requested reimbursement for facial feminization surgeries (21139, 14041, 21122, 30420, 15839 and 31899) performed on 11/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gender dysphoria.  The physician reviewer found that based on the medical documentation provided including a review of the photographs, the services at issue were not medically necessary. Facial feminization and tracheal shave surgeries can help to approximate a more feminine appearance. However, in this patients case, the photographs show that her facial structure is consistent with a female gender.  Her hairline does not show significant frontal bone prominence and her nose, chin, face and neck appear consistent with the female gender. There is a slight tracheal prominence but the photographs do not show evidence of a significantly prominent tracheal cartilage. In this case, the photographs do not show evidence of a masculine appearance of the brows, forehead, hairline, midface, and neck. These findings are relatively gender neutral and not atypical for a female. As such, this patient lacked evidence of abnormal facial structures for a female and her facial presentation is consistent within the spectrum of the female gender. Accordingly, the facial feminization surgeries (21139, 14041, 21122, 30420, 15839 and 31899) performed on 11/16/17 were not medically necessary for the treatment of this patient.
Therefore, for the reasons stated above, the services at issue were 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

The patient is a 49-year-old male with a history of acute trauma to the thigh resulting in a thigh compartment syndrome. He underwent an emergency fasciotomy; however, the submitted documentation indicates the treating surgeon was not familiar with post-surgical care. The record noted a 14-inch draining skin incision. The patient was transported by air ambulance from Florida to Dallas, Texas. The patient has requested reimbursement for air ambulance services provided on 11/25/17. The Health Plan has denied this request and reported that the services at issue were not medically necessary. This denial is the subject of this appeal and determination.  There is sufficient support in the documentation and the medical literature for the medical necessity of the services at issue. Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time are also crucial for optimization of functional and aesthetic outcomes. The patient had a 14-inch long draining wound and the submitted documentation indicates the initial surgeon was not familiar with current fasciotomy wound closure techniques. Transfer by air ambulance to a tertiary care institution was needed in light of the 14-inch long draining open wound and the patients pain. There was an urgent need for wound management at a tertiary care center to prevent deep infection, facilitate healing, and prevent complications such as deep vein thrombosis. The patient could not utilize public transportation due to the need for maximum assistance with ambulation. His ambulation was limited to use of bathroom only with assistance. He required dressing changes by medical personnel with sterile precautions as needed to keep wound clean during transport. While the record had noted that the patients vital signs were stable, stable vitals do not mean a sudden change in vitals cannot take place at any moment due to bleeding from an open wound. The presence of emergency medical personnel was essential. Tertiary care in Dallas, Texas was chosen because it was near his home. His treatment in Orlando, Florida would have necessitated a prolonged stay for follow-up care and inability to use public transportation. As noted above, the surgeon in Florida was unfamiliar with vacuum assisted closure.  Vacuum assisted closure technique has one of the lowest complication rates. In sum, air ambulance services provided on 11/25/17 were medically necessary for treating this patients medical condition. 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: Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for methylenetetrahydrofolate reductase (MTHFR) and nerve conduction velocity (NCV) studies provided on 9/22/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Hashimotos thyroiditis.   The physician reviewer found that based on current medical guidelines, the MTHFR and NCV testing performed on 9/22/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Neither of these tests are integral to the management and treatment of the patients hypothyroidism. While patients with hypothyroidism may experience neuropathy and muscle complaints, a NCV test is generally not indicated to diagnose or treat this condition. MTHFR testing has no role in the treatment of patients with hypothyroidism and Hashimotos thyroiditis. Recent data indicates that there is a lack of evidence for this type of testing in this clinical setting. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a seven-year-old male. He has been diagnosed with mixed receptive/expressive speech disorder, phonological disorder and severe apraxia of speech. The patientas parent has requested reimbursement for speech therapy provided from 1/01/19 through 12/30/20. The Health Insurer has denied this request and reported that the services at issue were 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 services at issue in this clinical setting. The patient has mixed receptive/expressive speech disorder, phonological disorder and severe apraxia of speech. His speech and language impairment is severely impeding his ability to communicate with his family, peers and teachers. He has been documented as consistently attending therapy sessions, and to be making progress towards goals, with new goals subsequently being introduced by the therapist. Law and colleagues performed a review on speech and language therapy interventions for children with primary speech and language delay or disorder. The authors noted, aOverall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. The evidence for expressive syntax difficulties is more mixed, and there is a need for further research to investigate intervention for receptive language difficulties.a Liu and colleagues noted, aThe ability to communicate effectively with others is central to childrenas development. Delays or disruptions due to isolated expressive language delay, articulation errors, multiple sound production errors with motor planning deficits, or mixed expressive and receptive language delay, often bring widespread consequences.a Capone Singleton noted that late talking in children who do not receive professional intervention places them at risk for lifelong disability. OaHare and Bremner emphasize the need for comprehensive speech and language assessment, and speech therapy, for children with speech and language difficulty. Therefore, speech therapy provided from 1/01/19 through 12/30/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 44-year-old male enrollee has requested authorization and coverage for Testim. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees testicular hypofunction. 
The physician reviewer found that low testosterone can lead to such complications as reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue (Dandona and Rosenberg). For these reasons, many providers treat patients with hypogonadism when a patients testosterone level is less than 350 ng/dL (Nieschlag, et al). The general target level for testosterone ranges from 350 to 750 ng/dL, in androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly (Rivas, et al). This patient has a history of hypogonadism, with documentation of low serum testosterone including levels of 275, 283, 300 ng/dL. Thus, the requested Testim is supported as medically necessary for treatment of this patients hypogonadism. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old male enrollee has requested reimbursement for air ambulance services provided on 5/12/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees brain tumor with mass effect and parenchymal hemorrhage. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. Pituitary apoplexy is considered an acute neurosurgical life threatening, emergency (Post et al; Briet et al; Vanderpump, et al). The potential for acute hemorrhage,  acute pituitary collapse with adrenal insufficiency, and blindness  requires emergency care and treatment (Muthukumar, et al; Nawar, et al; Rajasekaran, et al). Not all hospitals have the combination of neurosurgical with transsphenoidal abilities/endocrinologic/ophthalmologic and intensive care facilities. These services are a must for proper care of pituitary apoplexy (Rajasekaran, et al). In this clinical setting, UCSF was a closer facility with these capabilities than UCSD. Therefore, the ambulance services provided on 5/12/14 was not medically necessary in this patients case. For the reasons provided, 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

The patient is a 61-year-old male with a diagnosis of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Associated symptoms include nocturia, slow stream, and incomplete emptying. Prior failed therapy includes uroxatral. The patient has requested reimbursement for the UroLift procedure provided on 10/18/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational. The prostatic urethral lift (PUL) system is a novel, minimally invasive approach to treating BPH that lifts or holds the enlarged prostate tissue out of the way of the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift System treatment is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. Compared with standard available options, PUL is minimally invasive procedure without a requirement of general anesthesia with a potentially shorter operative time. A recent prospective, randomized, multinational study compared the outcome of PUL to transurethral resection of the prostate (TURP) and concluded that participants who underwent the PUL procedure responded significantly better than those who underwent TURP as therapy for BPH with regard to important aspects of quality of life (Snksen, et al). All told, the UroLift procedure provided on 10/18/16 was 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 service at issue was 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 15-year-old male who has been diagnosed with mixed receptive-expressive language disorder, cognitive communication deficit and other speech disturbances. The patientas parent has requested reimbursement and prospective authorization and coverage for speech therapy provided from 1/10/21 through 12/31/21. The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. This patient has been receiving speech therapy from two therapists. One therapist, Anna Vagin, PhD, coordinates a weekly group speech therapy session, facilitating the development of the patientas social language skills in a group setting. He is functioning below age-level in his communication skills. As such, he is at risk of being socially excluded and bullied, which may increase his risk of mental health problems unless he continues to receive medically necessary speech therapy to address improving his communication skills with his peers. His scores on the Comprehensive Assessment of Spoken Language (CASL-2) were very low. Ebbels and colleagues describe the effectiveness of speech and language therapy for older children with language disorders. The therapy provided by the second therapist, Brooke Gonterman, M.D., CCC-SLP, appears to be primarily educational in nature. Brooke Gonterman, M.D., CCC-SLP was working on school assignments with the patient, which appears educational rather than medically necessary in nature. As such, it does not appear to be medically necessary, and could be addressed in the school setting. Therefore, speech therapy services provided by Anna Vagin, PhD were and are medically necessary. Speech therapy services provided by Brooke Gonterman, M.D., CCC-SLP were not and are not medically necessary.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The patient is a 61-year-old female with a history of sarcoma. Per the records, positron emission tomography (PET) scan showed a thyroid nodule. A biopsy was consistent with atypia of undetermined significance. Therefore, the specimen was sent for genetic testing. The patient has requested reimbursement for the gene test provided on 12/21/16. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of this patient. There is sufficient support for the services at issue in this clinical setting. In this patients case, pathology was consistent with atypia of undetermined significance. The submission to genetic studies was appropriately done in this case, because it was important for medical decision making. The results of this testing were important to determine whether to perform thyroidectomy or not, and the extent of surgery. With a benign result, surgery may be avoided. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy, and no additional procedure is needed. In sum, gene test provided on 12/21/16 was likely to have been of greater benefit than other available modalities for 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 2

The patient is a 43-year-old female with major depressive disorder.  She reports insomnia and chronic pain. She has a history of a prior suicide attempt. The patient has been treated with a myriad of medications. She has also been treated with electroconvulsive therapy (ECT) and an incomplete trial of transcranial magnetic stimulation (TMS). The patient has requested authorization and coverage for CPT 64568 (implantation of vagus nerve neurostimulator electrode). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of this patient.  The submitted documentation fails to demonstrate the superior efficacy of the requested services. While a myriad of medications are listed, the doses and durations are not provided. Therefore, the adequacy of her medication trials cannot be established. It cannot be determined that she is a true medication non-responder based on the information provided. Based on the records, the patient may be a candidate for a recurrent trial of ECT, which is community standard. Vagus nerve stimulation is a longer term and less effective treatment than either ECT or TMS. All told, CPT 64568 (implantation of vagus nerve neurostimulator electrode) is not likely to be more efficacious than other available treatment options. 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: Upheld

Summary Reviewer 1 
 
A 54-year-old female enrollee has requested reimbursement for advanced lipoprotein testing 
performed on 4/15/22. 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 in this case, the American College of Cardiology calculated ten-year coronary 
artery disease risk score is in the low-risk range for this patient. Patients with high-sensitivity C-
reactive protein (hs-CRP) levels less than two do not have an increased risk of disease associated 
with elevated lipoprotein(a). There is a lack of data in current medical literature demonstrating 
that  the  lowering  of  lipoprotein(a)  in  patients  other  than  in  those  at  high  traditional 
cardiovascular risk is beneficial. While lipoprotein(a) testing may be reasonable in adults to aid 
in the clinician-patient discussion about whether to prescribe a statin in those aged 40 to 75 with 
borderline ten-year atherosclerotic cardiovascular disease risk, to identify a possible cause for a 
less-than-anticipated low-density lipoprotein cholesterol lowering, to use in cascade screening 
of family members with severe hypercholesterolemia, and to identify those at risk for progressive 
atherosclerotic cardiovascular disease, the submitted records did not demonstrate that this 
patient met any of these risk factors. The patient does not have a documented family history of 
premature coronary artery disease and has normal lipoprotein levels. Therefore, advanced 
lipoprotein testing performed on 4/15/22 was not likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 29-year-old male enrollee has requested authorization and coverage for Subsys. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose and short-acting opiates may contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Long-term opiates are more likely to cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose, opiates might induce tolerance and abnormal pain sensitivity.  All told, the requested medication Subsys is not likely to be of greater benefit than other treatment options.  Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a 15-year-old male enrollee has requested reimbursement for CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15. The Health Insurer has denied this request indicating that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Allergen immunotherapy is a long-term treatment that decreases symptoms for many people with allergic rhinitis, allergic asthma, conjunctivitis or stinging insect allergy.  Allergy shots decrease sensitivity to allergens and often lead to lasting relief of allergy symptoms even after treatment is stopped.  Indications for allergen immunotherapy include allergic asthma and rhinitis, conjunctivitis, as well as venom-induced anaphylaxis.  In this patients case, the records do not support the services at issue.  Without a diagnosis of asthma, rhinitis, conjunctivitis or anaphylaxis, the services at issue cannot be recommended.  In sum, CPT code 95165, professional services for the suppression and provision of antigens for allergen immunotherapy from 2/10/15 through 2/12/15 were not likely to have been of greater benefit than other treatment options.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.