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

Summary Reviewer 

The patient is a 41-year-old male who has been diagnosed with relapsing remitting multiple sclerosis. He was diagnosed in 2014 after an episode of optic neuritis and left leg tingling and was started on disease-modifying therapy (DMT) with Copaxone. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. The American Academy of Neurology issued practice guideline recommendations for disease-modifying therapies (DMTs) for adults with multiple sclerosis. As noted by Rae-Grant and colleagues, respecting patient preferences is an important component of care for chronic conditions. Because of the variety of DMTs available, evaluating patient preferences may improve acceptance of and adherence to DMT. The authors noted Because DMT requires adherence to
treatment to provide full efficacy, and because that adherence to treatment may be an issue for people with multiple sclerosis, discussing adherence issues before initiating DMT is part of good clinical practice. Efforts to increase adherence may improve outcomes. A systematic review by McCool and colleagues compared ocrelizumab with other disease-modifying treatments for relapsing multiple sclerosis. Per the authors, Results suggest that ocrelizumab has superior efficacy to 10 of the 17 treatments in the 12-week confirmed disability progression network and 12 of the 17 treatments in the annualized relapse rate network (both including placebo). The efficacy of ocrelizumab was comparable with the other treatments in both networks. In the serious adverse events and discontinuation due to adverse events networks, ocrelizumab demonstrated a safety profile comparable with all other treatments (including placebo). In this case, the patient has a diagnosis of relapsing remitting multiple sclerosis presenting with a recent relapse and active lesions on MRI. He was on DMT with Copaxone but had difficulty with compliance. The provider presented and weighed the options for DMT and determined that Ocrevus to be the best in terms of safety and compliance for the patient. Further, the results of studies as shown above suggest that ocrelizumab has an efficacy superior to or comparable with other currently approved DMTs. Therefore, ocrelizumab (Ocrevus) 300 mg 1 day and 15 day is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for residential treatment center services from 1/20/12 through 12/3/12. 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 residential treatment center services from 1/20/12 through 12/3/12 were not medically necessary for treatment of the patients medical condition. The additional documentation submitted for review demonstrates that the patient benefited from living in a sober living environment, in which he was drug free. However, these records do not indicate that within that environment he received any specialized medical or nursing treatment that was medically necessary for 24-hour residential treatment level of care. He had monthly psychiatric treatment, as well as group and individual therapy. He was at least minimally cooperative with his treatment, as documented every month by his attending psychiatrist. He did not require any special treatments, and was not documented to be suicidal, homicidal or psychotic. Based on the additional records submitted for review, this patient could have been treated in a less restrictive setting, such as a therapeutic boarding school with treatment provided through outpatient services. In addition, the neuropsychological performed in September 2012 assessed the patient with conduct disorder and stated that he does not have anxiety or depression. Moreover, the second evaluation, performed in 2013 also failed to find current evidence of a depressive disorder, and only stated that the patient has a history of major depressive disorder and oppositional-defiant disorder. In summary, the additional records submitted for review do not provide evidence that placement in a residential treatment center was medically necessary. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 39-year-old female enrollee has requested authorization and coverage for cervical transection 
and avulsion of extraspinal nerve. The Health Insurer has denied this request and reported that 
the requested services are investigational for the treatment of the enrollees medical condition. 
The  physician  reviewer  found  that  per  the  submitted  documentation,  the  provider  has 
recommended endoscopic rhizotomy to address axial neck pain. In this case, the levels being 
requested are C2-3 and C3-4. The provider noted that the patient is status post C3-5 fusion. 
Percutaneous radiofrequency ablation is considered the gold standard treatment for axial neck 
and back pain caused by facet joint pathology. However, fluoroscopically guided percutaneous 
radiofrequency ablation does not allow for direct visualization of the targeted medial branch 
nerves. It has been suggested that endoscopic visualization will provide better outcomes due to 
the ability to directly visualize the targeted nerves. It should be noted that radiofrequency 
ablation is not generally performed on previously fused levels. In this case, one of the levels being 
requested appears to have been previously fused. The study by Yeung and colleagues was a 
retrospective non-randomized study. It did not include direct comparison with radiofrequency 
ablation or intra-articular facet steroid injection. Additionally, it did not address the procedure in 
the cervical spine or address performing this procedure on previously fused levels. Meloncelli 
and  colleagues  performed  a  prospective  cohort  study.  This  study  did  not  include  direct 
comparison with radiofrequency ablation or intra-articular facet steroid injection. Additionally, it 
did not address the procedure in the cervical spine or address performing this procedure on 
previously fused levels. Xue and colleagues performed a randomized controlled trial comparing 
radiofrequency ablation with endoscopic rhizotomy. The outcomes were similar until the 6 and 
12 month follow-ups, at which point the experimental group had statistically significant reduction 
in pain. However, this study involved a small sample size and short follow-up time. The long-term 
efficacy needs further follow-up studies. Additionally, there was no identification of improved 
functional outcomes from endoscopic rhizotomy. Furthermore, the study did not address the 
procedure in the cervical spine or address performing this procedure on previously fused levels. 
At this time, the current medical evidence has not established the superior efficacy of the 
requested services in this setting. Therefore, cervical transection and avulsion of extraspinal 
nerve is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for Repatha.  The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollee, who has a history of atherosclerotic cardiovascular disease. The physician reviewer found that per the records, this patient has known coronary disease, documented intolerance to moderate and higher dose statin medications and elevated low-density lipoprotein level above goal despite the combination of highest tolerable statin dose and ezetimibe.  In this circumstance, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is reasonable and appropriate based on current evidence.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein levels.  This patient fits the latter criteria.  However, the Health Insurer has offered coverage for Praluent as an alternative. Praluent is also a PCSK9 inhibitor and is a reasonable alternative to Repatha. Thus, although a PCSK9 inhibitor is medically appropriate, the records do not demonstrate the medical necessity of Repatha as opposed to the alternative medication Praluent. In sum, Repatha is not medically necessary for the treatment of this patient. Therefore, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
 
A 50-year-old female enrollee has requested authorization and coverage for interstitial radiation 
source application, complex, includes supervision, handling, loading of radiation source, when 
performed. The Health Insurer has denied this request and reported that the requested service 
is investigational for the treatment of the enrollees oligoprogressive hepatic disease. The 
physician reviewer found that current medical literature does not support the use of liver 
radioembolization in the treatment of patients with widespread metastatic disease. Hong and 
colleagues report that the American College of Radiology (ACR), American Brachytherapy Society 
(ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology 
(ASTRO),  Society  of  Interventional  Radiology  (SIR),  and  Society  of  Nuclear  Medicine  and 
Molecular Imaging (SNMMI) practice parameter on selective internal radiation therapy (SIRT) or 
radioembolization for treatment of liver malignancies note that liver radioembolization is only  recommended for patients with liver-dominant metastatic disease, where the cancer is primarily 
confined to the liver and has not spread to other parts of the body. Liver radioembolization 
carries  the  risk  of  complications  such  as  liver  damage  and  bile  duct  injury.  The  National 
Comprehensive  Cancer  Network  (NCCN)  guidelines  do  not  endorse  the  routine  use  of 
radioembolization  in  the  treatment  of  metastatic  lung  cancer.  In  the  case  of  widespread 
metastatic disease, the risks of liver radioembolization are likely to outweigh any potential 
benefits.  Overall,  the  available  evidence  and  national  guidelines  suggest  that  liver 
radioembolization is not necessary in the treatment of patients with widespread metastatic 
disease. The standard treatment for metastatic EGFR lung cancer typically involves the use of 
targeted therapies such as tyrosine kinase inhibitors, which block the activity of the EGFR protein, 
or systemic chemotherapy. These standard treatments are effective in slowing the growth and 
spread  of  cancer.  There  is  a  lack  of  trials  in  current  medical  literature  showing  that 
radioembolization is superior in any oncologic outcome compared to standard treatment with 
tyrosine kinase inhibitors or chemotherapy. Therefore, interstitial radiation source application, 
complex, includes supervision, handling, loading of radiation source, when performed, is likely 
not to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 39-year-old male enrollee has requested reimbursement for ambulance transportation provided on 6/26/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that submitted documentation fails to demonstrate the medical necessity of the services at issue. The Health Insurer denied prior authorization for ambulance transportation to University of California San Diego Medical Center. The reason cited was that there were other facilities closer to Cincinnati, Ohio which were capable of performing pulmonary thromboendartectomy. The alternative plan was to transfer the patient by ground to Cleveland, Ohio. The records noted that the patient and his provider selected University of California San Diego Medical Center because it performs many pulmonary thromboendartectomy procedures and has a low mortality rate. This patient was not transferred on an emergency basis. The patient was medically stable at Christ Hospital. He was appropriate to be discharged home. The patients vital signs were stable at the time of transfer. There were medical facilities closer to Cincinnati, Ohio which were capable of performing pulmonary thromboendartectomy. Therefore, ambulance transportation provided on 6/26/18 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 32-year-old male enrollee has requested reimbursement for gene testing (DecisionDx-Melanoma testing) performed on 1/23/19. 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 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 a 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 (DecisionDx-Melanoma testing) performed on 1/23/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
  A 43-year-old male enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve first two bodies, lumbar or sacral. The Health Insurer has 
denied  this  request  and  reported  that  the  requested  services  are  investigational  for  the 
treatment of the enrollees medical condition. The physician reviewer found that current medical 
literature  supports  the  use  of  the  Intracept  procedure  as  a  minimally  invasive  outpatient 
procedure that has been demonstrated as safe, effective and durable. It is implant-free and 
preserves spinal integrity by negating the need for extensive tissue exposure and disruption, and 
in most cases, pain relief is fairly rapid. Fischgrund and colleagues found that patients with 
chronic low back pain treated with ablation of the basivertebral nerve exhibited sustained clinical 
improvements in function and pain with high responder rates at a mean of 6.4 years following 
treatment, confirming the long-term effectiveness and durability of basivertebral nerve ablation. 
In this case, in a letter dated 5/20/22, the provider reported that the patient has a history of 
severe chronic low back pain that severely limits his activities of daily living. He has tried and 
failed the full measure of conservative treatment including NSAIDs, facet injections, extensive 
physical  therapy,  acupuncture,  chiropractic  treatments,  massage  treatments,  and  a  home 
exercise program. An MRI demonstrated Modic changes at the L3-L4 disc space, which is strongly 
associated with chronic vertebrogenic low back pain. The submitted records did not demonstrate 
that  more  invasive  interventions,  such  as  extensive  decompression  and  fusions  or  disc 
replacements,  would  be  warranted.  Given  this  patients presentation,  which  included  MRI 
findings that showed Modic endplate changes, and young age, the requested service is likely to 
be more beneficial than a more invasive surgery. Therefore, thermal destruction of intraosseous 
basivertebral nerve first two bodies, lumbar or sacral is likely to be more beneficial for treatment 
of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for physical therapy/acupuncture provided from 2/01/19 through 4/08/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that Osteochondromatosis can cause various clinical issues, including impingement of nerves, causing chronic pain and neurological symptoms and reducing quality of life. Management can include analgesics and other palliative measures. There is no role for prolonged physical therapy for this condition per se, except to address functional issues as needed. In this case, the patient has had pains and functional symptoms. She underwent physical therapy for a prolonged period of time that included various exercises and palliative interventions. As of the time period under review, although she continued to have symptoms, there were no indications that she could not have performed an independent exercise and palliative measure program to address her chronic symptomatology. More physical therapy would not have been expected to positively impact her clinical course or outcomes. The physical therapy in question was not medically necessary for the treatment of this patient. All told, physical therapy/acupuncture provided from 2/01/19 through 4/08/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 36-year-old female enrollee has requested reimbursement for AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who underwent open reduction and internal fixation. The physician reviewer found that the superior effectiveness of the services at issue has not been established. There is a paucity of substantive research supporting the use of AmnioFix graft in this setting. The medical evidence has not demonstrated that the use of AmnioFix is more efficacious than standard techniques. The use of these types of products is poorly researched at this time. Thus, AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18 was not likely to have been more effective than other treatment modalities. 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: Upheld

Summary Reviewer 1

A 32-year-old male enrollee has requested reimbursement for gene testing performed on 3/12/19. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 patients, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients undergoing sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma data relates to the ten-year Balch data. Most importantly, it is unknown if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing performed on 3/12/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 31-year-old female enrollee has requested authorization and coverage for rituximab injection therapy. The Health Insurer has denied this request indicating that the requested therapy is considered investigational for treatment of the enrollees multiple sclerosis, relapsing-remitting. The physician reviewer found that rituximab is a monoclonal antibody therapy that has been utilized on an off-label basis for patients who have not responded to traditional multiple sclerosis (MS) therapies. Although rituximab is considered off label therapy for MS, results from the two rituximab MS trials were promising.  In a trial involving 439 patients with RRMS, those receiving rituximab experienced substantially fewer relapses and developed 92% fewer enhancing magnetic resonance imaging (MRI) lesions during the 48 weeks of the trial than those receiving placebo. In a trial involving patients with primary progressive MS, fewer people in the rituximab group (30.2%) experienced disability progression than in the placebo group (38.5%) after 96 weeks. Although the difference was within a range that might have occurred by chance, preplanned subgroup analysis detected a clear benefit for younger people and people with inflammatory MRI lesions. Furthermore, current trials have shown positive results. Based upon the information set forth above, the requested therapy is likely to be more effective for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.