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

Summary Reviewer 

The patient is a 15-year-old female diagnosed with major depressive disorder, recurrent, severe, alcohol use disorder, severe, and self-harm. The patient was admitted to intensive outpatient program (IOP) treatment on 1/19/17. The clinical record documents discord between the patient and her family. During the course of treatment, the patient has described herself as a mediator between her parents. An entry on 2/8/17 reveals that she was allowed to go on a trip with her father from 2/9/17 until 2/13/19, while in IOP. On 4/10/17, the patient reported less suicidal ideation but continued mood symptoms thus Prozac was increased from 20 mg daily for 30 mg daily with a plan to reassess in five weeks. Also on 4/10/17, she indicated in group that she does not express her anger in adaptive ways and she acknowledged that she wanted to learn more adaptive strategies. Her parent has requested reimbursement and prospective authorization and coverage for mental health IOP services from 4/10/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary. The additional information provided has been reviewed. On 5/24/17, an entry indicates that clients and parents attended a multifamily group. However, there is no indication the session focused on the specific issues and needs of this patient. Progress notes from other group encounters are similarly not specific to this patients needs and do not tailor care to the diagnoses and circumstances of the patient. Individual outpatient therapy and focused parent-child intervention in a less restrictive environment is likely to be more effective. More specific and focused treatment could be provided in a less restrictive setting. Accordingly, the IOP services provided from 4/10/17 forward were not and are not medically necessary for treatment of this patients behavioral health issues.  Based on the foregoing discussion, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of an eight-year-old male enrollee has requested reimbursement for FirstStep Dx Plus testing performed on 5/28/14.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the clinical literature supports CMA as a primary screening test for autistic children (Miller, et al; Manning and Hudgins). The article by McGrew and colleagues concluded that CMA should be the clinical standard in all specialties for first tier genetic testing in ASD. In addition, this patient has additional factors to validate the need for the CMA testing.  He carries the dual diagnoses of autism and ADD, which also suggests a multi-factorial genetic etiology. CMA is a routine part of the evaluation of an autistic child, whether or not the child is intellectually disabled or if dysmorphic features are noted (Miller, et al). In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was 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

A 48-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/12/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines state 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. The results of the services at issue were unlikely to have altered treatment and surveillance recommendations. In sum, DecisionDx-Melanoma testing performed on 12/12/17 was not likely to have been of greater benefit than other available 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 3


A 28-year-old female enrollee has requested reimbursement for CPT code 92025 (computerized corneal topography, unilateral or bilateral, with interpretation and report) provided on 6/02/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the superior effectiveness of the services at issue.  Dry eye syndrome is a chronic, multi-factorial problem.  This patient has been treated with topical lubricants, medication, and punctual plugs.  Corneal topography is a method of measuring the three-dimensional shape of the cornea.  It is useful for evaluating structural abnormalities of the cornea.  While dry eye syndrome can cause interference with corneal topography, dry eye syndrome is not related to the three-dimensional shape of the cornea, and cannot be meaningfully evaluated by corneal topography.  In sum, the superior efficacy of the services at issue has not been established.  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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 66-year-old female enrollee has requested authorization and coverage for ablation of varicose veins, right and left accessory ablation.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that while endovenous ablation of the greater saphenous vein has been extensively evaluated in the treatment of varicose veins, little is known about the efficacy in the treatment of accessory saphenous veins.  Furthermore, patterns of recurrence of varicose veins after greater saphenous vein treatment is usually new reflux in the accessory saphenous vein and there is little evidence available to guide optimal therapy, in contrast to greater saphenous vein interventions.  Therefore, given the absence of evidence for the efficacy of endovenous ablation of accessory saphenous veins after surgical therapy of greater saphenous vein incompetence, the superior effectiveness of the requested services has not been established.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 48-year-old female enrollee has requested authorization and coverage for implantation of Strattice. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees abdominal hernia. The physician reviewer found that based on peer reviewed medical literature, Strattice is an effective product for treatment of abdominal wall hernias and is available in a size appropriate for the patients condition. Strattice is a non crosslinked decellularized porcine xenograft which is comparable to Alloderm, a decellularized human allograft. Patel and colleagues (2011) reported a study of 78 complex patients with component separation abdominal ventral hernia repair with Strattice reinforcement. There was 12% exposure rate, but all patients went on to complete healing without explantation. They concluded that Strattice is an effective adjunct to abdominal wall reconstruction (AWR) when used as reinforcement in component separation ventral hernia repair. Patel and colleagues (2013), in a review of 41 patients with complex AWR and Strattice underlay from 2007-2010, state that all patients achieved abdominal wall closure with no recurrent hernias or need for Strattice removal. They concluded that patients with multiple comorbidities at intermediate risk of postoperative complications can achieve successful, safe AWR with Strattice. All told, implantation of Strattice is likely to be more effective than the standard options available for treatment of this patients medical condition. Therefore, for the reasons stated above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
A 40-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral, on 8/26/21. The Health Insurer has 
denied this request and reported that the service at issue was investigational for the treatment of 
the enrollees bilateral eustachian tube dysfunction. The physician reviewer found that there are 
limited treatments for eustachian tube dysfunction, including medical management, myringotomy 
and tube placement, and more recently, eustachian tube balloon dilation. Tucci and colleagues 
report, At this time, additional randomized controlled trials with longer follow-up are still 
necessary to establish a higher level of evidence for balloon dilation of the eustachian tube 
efficacy.  The authors further noted a lack of consensus regarding the overall short-term or long-
term effectiveness of Eustachian tube balloon dilation. Froehlich and colleagues note, Eustachian 
tube balloon dilation appears to be associated with improvement in subjective and objective 
treatment outcome metrics at three to 12 months after dilation. However, the authors noted that 
only  50.5%  of  patients  had  improved  tympanograms  and  55.4%  had  normal  otoscopy 
examinations in the long term. In a randomized controlled trial comparing balloon dilation to 
medical management that evaluated patients ETDQ-7 scores at six weeks and at 12 months, 
Meyer and colleagues reported that balloon dilation was a safe and effective treatment. However, 
this trial included only 31 patients treated with balloon dilation and 29 patients as control. There 
are a lack of studies comparing balloon dilation to myringotomy tube placement. In this setting, 
clinical evidence in published current medical literature is insufficient to show that eustachian tube 
balloon dilation is more effective for the treatment of eustachian tube dysfunction than standard 
treatment  with  medical  management  or  with  myringotomy  and  tube  placement.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral, on 
8/26/21, was not likely to have been more beneficial for treatment of the patients condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 66-year-old female enrollee has requested authorization and coverage for gene testing provided on 12/28/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDX-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, there are no definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials according to published data available. Per the National Comprehensive Cancer Network (NCCN) guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following SLNB) is not recommended outside of a clinical study (trial).  In sum, gene testing performed on 12/28/15, was not likely to have been more beneficial than any available standard of care in evaluating this patient. 
Therefore, for the reasons stated above, the services at issue were not likely to have been 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: Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment services provided from 8/26/15 through 12/31/16. 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 the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient could have been treated in a lower level of care from 10/19/17 through 10/25/17. On 10/17/17, the patient weighed 120.40 pounds and was 102% of her IBW. The patient had exceeded her ideal body weight of 118 pounds. The patient was engaged during her therapy sessions and she completed 98% of her meal plans over the week. She continued to struggle with anxiety and depression but she reported to staff on many occasions that she felt that the RTC level of care was excessively restrictive for her and she had a desire to be discharged. The patient did not report any suicidal ideation or homicidal ideation. The patient was medically stable. By 10/19/17, she no longer required 24 hour supervision. It is standard of care to treat patients in the least restrictive environment possible. This patient continued to require treatment for her eating disorder but her treatment could have been accomplished at a less restrictive environment. Accordingly, the eating disorder RTC services from 10/19/17 through 10/25/17 were not medically necessary for the treatment of this patients medical condition. Based upon the information set forth 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 


A 42-year-old female enrollee has requested authorization and coverage for Trokendi XR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees migraine headaches. The physician reviewer found that there is sufficient support in the medical literature and in the submitted documentation for the requested medication. Trokendi XR is an extended release version of topiramate. Its pharmacokinetic studies indicate smoother exposure, and less variation of blood levels compared to the immediate release formulation. Studies indicate better tolerability, fewer side effects, and better patient acceptance. Clinical notes in this case also indicate that the patients tolerability has been better at comparable doses. A review of topiramate studies in migraines treated with extended release topiramate support a clinically meaningful benefit of extended release topiramate versus immediate release topiramate in terms of significantly fewer cognitive effects, improved adherence, and overall better outcomes of migraine prophylaxis with topiramate. Based on the clinical notes, she has done better with Trokendi then the generic, immediate release. Trokendi XR is U.S. Food and Drug Administration approved and indicated for migraine prevention. While it has the same active ingredient as generic topiramate, it is not therapeutically equivalent as evidenced by studies as well as in this patient. All told, Trokendi XR is medically necessary for treatment of this patients medical condition.Therefore, for the reasons stated above, 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: Overturned

Summary Reviewer 


A 32-year-old male enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b. 

 The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. 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 

The parent of a 17-year-old female enrollee has requested reimbursement for psychiatric residential treatment center services provided from 7/17/18 through 9/13/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. She did engage in some self-harm behavior prior to her treatment. In terms of functional status, the records support a score of 3. The patient had issues with level of functioning due to mental illness in the past. She had been missing school due to her anxiety and withdrew from school in March 2018. During the initial portion of treatment, it was noted that she would at times go a few days between showers. With regards to comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use that affected primary psychiatric issues. In terms of level of stress of the recovery environment, the records support a score of 2. There was no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. She showed engagement with providers, and previous treatment had not been successful in optimal relief of symptoms. In terms of acceptance and engagement of the patient, the records support a score of 2. The patient was hesitant to participate in treatment after admission for a brief timeframe. Overall, she was cooperative in treatment. With regards to acceptance and engagement of the parents, the records support a score of 2. The parents worked actively and constructively with clinicians on a regular basis. Therefore, the patient has a composite score of 17. This score correlates with intensive outpatient services. Therefore, psychiatric residential treatment center services provided from 7/17/18 through 9/13/18 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 45-year-old male enrollee has requested authorization and coverage for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. After implantation of metal and metal methylmethacrylate devices in the knee and hip, it has been demonstrated that the patients are exposed to particulate debris. This particulate debris consisting of abrasive wear and adhesive contact wear between the components of the device elicit a chronic inflammatory reaction including a giant cell tissue response. The effect of this exposure may vary from patient to patient but all patients will be exposed to the consequences of wear. Moreover, fusion at the L5-S1 level is not likely to effectively eliminate chronic inflammation with pro-inflammatory cytokines mediating the patients ongoing experience of lumbosacral regional pain. The extent of neural foraminal stenosis at L5-S1 is minimal based on two separate MRI studies performed. The clinical examination does not demonstrate motor deficits or sensory pattern changes beyond pain changes, and there is no definite evidence for spinal nerve root compromise. In this clinical setting, ongoing conservative management and continued observation is likely be more beneficial than surgical treatment plans. Accordingly, the request for hybrid artificial disc replacement at L4-5 and fusion at L5-S1 (CPT codes 22558, 22851, 22585, 22845, 20930, 63090, 63091 and 77003) are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.