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

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for residential mental health treatment for children and adolescents provided form 5/29/17 through 8/17/17. 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 in cases such as this, an evidence-based instrument such as American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) assists in determining the necessary level of care for children. With regards to risk of harm, the records support a score of 1. The medical records indicate that the patient was not actively or passively suicidal, and there were no reports of self-harm. In terms of functional status, the records support a score of 2. The patient had some issues with level of function due to mental illness and relational issues, but overall showed appropriate daily functioning while in treatment. With regards to comorbidity, the records support a score of 1. The patient did not have a history of past medical issues and denied substance use. In terms of level of stress of the recovery environment, the records support a score of 2. The patient was noted to have interpersonal conflict with family members in the past, although she spoke well of her family. With regards to level of support of the recovery environment, the records support a score of 2. The patients parents were involved in treatment. In terms of resiliency and treatment history, the records support a score of 3. Per the records, the patient had some response to past outpatient treatment but continued to have some depression symptoms despite this treatment. With regards to acceptance and engagement of the patient, the records support a score of 2. The patient participated in therapy actively, and she was cooperative with consistent engagement. In terms of acceptance and engagement of the parents, the records support a score of 2. The patients parents worked actively and constructively with staff. Thus, the patient has a composite score of 15. This score correlates with outpatient services. Therefore, residential mental health treatment for children and adolescents provided from 5/29/17 through 8/17/17 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3



A 28-year-old male enrollee has requested reimbursement for Prometheus Anser ADA diagnostic test performed on 12/30/15. 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 that there is a lack of support as to the superior efficacy of the services at issue in this clinical setting.  In this patients case, Anser ADA was ordered to direct the management of the patients Crohns disease. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. The effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with Humira (adalimumab) may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature (Karmiris, et al; Imaeda, et al; Lichtenstein, et al). These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Karmiris and colleagues found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking. The available data does not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab. A study by Yanai and Hanauer concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response. As such, clinical literature does not support the superior efficacy of Prometheus Anser ADA diagnostic test performed on 12/30/15 over standard therapy in the evaluation of 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: Overturned

Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement for acute detoxification treatment provided from 12/31/15 through 1/4/16. 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 according to the documentation submitted for review, the patient presented with a history of alcohol use which included blackouts and withdrawal symptoms. He was drinking heavily on a daily basis. He was also having significant intrapsychic and psychosocial distress in context of underlying anxiety and depression. Considering these factors, the patient was at-risk for a complicated withdrawal syndrome thus the admission for supervised detoxification was initially medically necessary. While hospitalized, the primary detoxification modality was a benzodiazepine taper, which is standard of care.  On 1/1/16, the patients blood pressure was 144/100. His Clinical Institute Withdrawal Assessment for alcohol scale tallied 11 out of 67 (scores of 10 or less usually do not require medication therapy). On 1/2/16, the patient was normotensive. He was improving.  He was euthymic. There were no significant withdrawal or acute psychiatric symptoms noted. The patient was active in discharge planning. A family session was planned for 1/3/16. He did not want to attend intensive outpatient or residential programming, but intended to resume Alcoholics Anonymous. A follow-up appointment was arranged for 1/7/16. On 1/3/16, the patients tremor had resolved. He reported feeling well physically. Based on the documentation provided, as of 1/3/16 the patient had improved clinically. He had no history of complicated or protracted withdrawal. He had aftercare services in place. Thus, discharge on 1/3/16 to a less restrictive setting would have been safe, appropriate and consistent with good medical practice. All told, the acute detoxification treatment provided from 12/31/15 through 1/2/16 was medically necessary for treatment of the patients medical condition. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 34-year-old female enrollee has requested reimbursement for genetic testing for birth defects performed on 3/28/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found screening for aneuploidy via cfDNA screening has been shown to be an appropriate methodology for high-risk women, as established by current American Congress of Obstetricians and Gynecologists (ACOG) guidelines. Per guidelines, high-risk conditions include age at or over 35 at time of delivery or a history of a prior pregnancy affected with one of the aneuploidies screened for by this test. Based on the clinical documentation submitted for review, the patient is not a high-risk patient warranting cfDNA screening. In sum, the genetic testing for birth defects performed on 3/28/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.ased 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 43-year-old female enrollee has requested reimbursement for the blood testing provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees cardiovascular risk. The physician reviewer found that based on the records provided, this patient has no documented increased coronary risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL cholesterol, LDL particle number, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis (Lonn; Toole, et al). Moreover, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. All told, the blood testing provided on 1/17/17 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 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 37-year-old female enrollee has requested reimbursement for gene testing provided on 9/16/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has human epidermal growth factor receptor 2 (HER2) positive metastatic breast cancer. The options for treatment include Navelbine/Herceptin/Perjeta and Tykerb and Xeloda, and trastuzumab emtansine (T-DM1). Foundation One gene testing was not likely to aide in regimen selection. As such, the gene testing provided on 9/16/15 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 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: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of an eight-year-old male enrollee has requested authorization and coverage for Exondys 51. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Duchenne muscular dystrophy. The physician reviewer found that there is sufficient support for the requested medication in this patients case. Antisense oligonucleotide therapies continue to improve, and the key issue of providing sufficient concentration of antisense oligonucleotides to affected muscle fibers remains at the forefront of drug development for Duchenne muscular dystrophy. From a clinical standpoint, this patient has maintained a remarkably stable neuromuscular examination since starting the therapy in 2015. Therefore, Exondys 51 is likely to be more effective than 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 59-year-old female who has FLT3 positive acute myeloid leukemia status post a 
matched related donor peripheral blood stem cell transplant (SCT) on 1/17/22. The patient has 
requested authorization and coverage for Promacta (eltrombopag) 50 milligrams daily and 
increase depending on response. The physician reviewer found that the submitted 
documentation supports the medical necessity of the requested medication. The incidence of 
delayed thrombocytopenia in patients who undergo allogeneic hemopoietic stem cell 
transplant (SCT) is nearly 20-40%. Persistent thrombocytopenia after stem cell transplantation 
can lead to increased morbidity and mortality. Although the National Comprehensive Cancer 
Network (NCCN) guidelines recommend participation in a clinical trial for patients with 
thrombocytopenia after SCT, there are currently no clinical trials available. Use is supported by 
a phase II trial and a meta-analysis involving over 300 patients indicating safety and efficacy. 
This patient also requires HLA matched platelets in a current environment of severe shortages 
of blood products. There is sufficient support for the requested medication in this setting. 
Therefore, Promacta (eltrombopag) 50 milligrams daily and increase depending on response is 
medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 27-year-old male enrollee has requested reimbursement and prospective authorization and coverage for outpatient psychological services provided from 6/6/17 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 anxiety, depression, intrusive and recurrent thoughts, and migraines. The physician reviewer found that although weekly individual psychotherapy may be medically necessary for treatment of this patients medical condition, based on the documentation provided, the services in dispute were not and are not medically necessary. The criteria for PTSD, anxiety disorder, obsessive compulsive disorder, functionally impairing depression or specific phobia have not been established in the medical records. In addition, the treatment plan from August 2017 did not include critical elements such as the implementation of validated rating scales to guide treatment or the articulation of specific, measurable, attainable, relevant and timely patient-generated goals. Considering the diagnostic uncertainty and chronicity of symptoms, the records lack an updated psychological assessment and comprehensive outpatient treatment plan to determine the patients diagnoses, current clinical status and treatment needs. Depending on the evaluation, an evidence based psychotherapy and/or particular treatment modality may be deemed reasonably expected to improve the patients condition and prevent a more serious episode of illness based on the diagnosis. However, based on the documentation provided for review, the outpatient psychological services provided from 6/6/17 forward were not and are not medically necessary for treatment of this patients medical condition. Based on the above 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old female enrollee has requested authorization and coverage for the Flexitouch pneumatic compression pump system. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary for treatment of the enrollees lymphedema. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  This patient has pain associated with lymphedema.  Her provider has ordered a multimodality approach to treatment, including exercise, diet and decongestive lymphatic therapy (manual lymphoid drainage).  The patient has requested coverage for the Flexitouch pneumatic compression pump system versus the standard segmented pneumatic compression devices that the Health Insurer approves.  There is a lack of evidence indicating that a pneumatic compression device with calibrated gradient pressure (the Flexitouch pump) is more effective than standard segmented pneumatic compression devices.  All told, the requested Flexitouch pneumatic compression pump system is not medically indicated for the treatment of this patient.  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: Overturned

Summary Reviewer  
 
This patient is a 55-year-old female with a history of morbid obesity and several weight related 
medical problems including prediabetes, gastroesophageal reflux disease (GERD), and mixed 
hyperlipidemia. On 11/30/22, the patient completed her preoperative psychological evaluation, 
and the provider noted that the patient was an appropriate candidate for surgery. The Health 
Insurer has denied the requested services not medically necessary. The physician reviewer found 
that new updated bariatric guidelines from the American Society for Metabolic and Bariatric 
Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders 
(IFSO) published in 2022, provide medical evidence to support the safety and efficacy of bariatric 
surgery in patients with a BMI of at least 35 kg/m2, with or without the presence of severe obesity 
related comorbid conditions (Eisenberg, et al.). The current BMI eligibility guidelines were 
published to replace and update the older existing National Institutes of Health (NIH) consensus 
guidelines. The ASMBS and IFSO guidelines state that bariatric surgery may be considered in any 
patient  with  BMI  of  at  least  35  kg/m2  or  greater  with  or  without  other  severe  obesity 
considerations and in patients with a BMI of at least 30 kg/m2 with comorbid metabolic disorders 
such as diabetes. The records document that this patient has a BMI of 36 kg/m2. In addition, the 
patient has completed a comprehensive multidisciplinary evaluation and meets criteria with a 
BMI of 35 kg/m2. Given this support, the requested bariatric surgery and inpatient stay are 
medically necessary for treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 
The patient is a 46-year-old female who has requested reimbursement for laboratory testing (81219 and 81403) provided on 6/29/20.  The patient has requested reimbursement for laboratory testing (81219 and 81403) provided on 6/29/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the patients medical condition. This denial is the subject of this appeal and determination. The physician reviewer found that myeloproliferative disorders, such as essential thrombocytosis, polycythemia vera, and primary myelofibrosis, are suspected when a patient has persistent leukocytosis and thrombocytosis. Usually, platelets are persistently elevated above 500, white blood cell count is above 30 and some abnormal appearing white blood cells are usually seen. On 6/29/20, this patient had a normal white blood cell count and platelets, and a peripheral smear was described as normal. Based on these findings, a myeloproliferative disorder would be of low suspicion and further confirmatory tests such as JAK2 V617F cascading reflex to CALR, JAK2 exon 12, MPL, and CSF3R would not be indicated. There is a lack of support for the services at issue in this clinical setting. Therefore, laboratory testing (81219 and 81403) provided on 6/29/20 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 19-year-old female enrollee has requested reimbursement for residential treatment center services provided from 4/1/15 through 6/30/15 and 8/1/15 through 8/13/15. 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 RTC services provided from 4/1/15 through 6/30/15 and 8/1/15 through 8/13/15 were not medically necessary for treatment of the patients medical condition. To objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. As of 4/1/15, the patients risk of harm score is two (2), mild risk of harm. The patient has a history of self-injurious behavior. There was no documentation of prior suicide attempts. However, on 4/1/15, the patient did not have any suicidal ideation and had not had any recent self-injurious reports. The patients functional status score is two (2), mild functional impairment. By 4/1/15, the patient had made much improvement. She was focusing on her schoolwork. Her sleep, appetite, and mood were normal. There were no changes made to her Wellbutrin dosage. The patients co-morbidity score is three (3), significant co-morbidity. The patient has a co-morbidity of cognitive disorder NOS and depressive disorder NOS. The patient also has damaged lungs and vocal cords. However, from the documentation, it did not appear that the patient required 24 hour assistance. The patients recovery environment stress score was three (3), moderately stressful environment. The patients biological father and step-mother are going through a divorce. The patient is very close to her step-mother. The patients environmental support score is two (2), supportive environment. The patients father and stepmother are supportive of the patient. The patients resiliency score is two (2), significant response to treatment. By 4/1/15, documentation attests that the patient has made significant response to treatment. The patients acceptance and engagement, score (1), optimal. The patient has positive relationships with providers. She actively participates in treatment planning and cooperates with treatment. Based on these criteria, the patient has a composite score of 15, which would meet criteria for outpatient treatment. The patient continued to need treatment for her cognitive disorder NOS, depressive disorder NOS, and parent-child relational problem, but this could have been safely and adequately provided in a less restrictive environment. 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.