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

Summary Reviewer 

A 53-year-old female enrollee has requested authorization and coverage for fenofibric acid DR. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hypertriglyceridemia. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a history of Crohns disease, severe hypertriglyceridemia leading to pancreatitis and documented intolerance/ineffectiveness to several medications including fenofibrate at doses ranging from 48 mg to 145 mg. She is now tolerating a related medication (fenofibric acid 135 mg DR) that is also effective at lowering triglyceride levels. Her condition is life-threatening. Thus, it would be unsafe to trial the fenofibrate doses on the Health Insurers preferred formulary. In addition, there is improved bioavailability with the patients current fenofibric acid medication that may be important given her partial small bowel resection and colectomy. In summary, given the patients life threatening condition, trials and intolerance/ineffectiveness of several fenofibrates, stability and effectiveness on current medication and potential advantages of her current medication over formulary alternatives, the requested fenofibric acid DR is medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

An 81-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 7/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities because many patients will not require therapy (i.e. surgery or radiation) and may be followed closely instead. Most clinical variables have not been analyzed in prospective clinical trials. The important features to recognize are Gleason score and PSA, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients (1-3). The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. Therefore, Oncotype DX Prostate testing performed on 7/23/20 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient presented in December 2018 with chronic bilateral heel pain. She was diagnosed with bilateral plantar fasciitis. She had reportedly failed conservative treatment, including steroid injections, orthotics, stretching, rest, ice, elevation, therapy, activity modification, and shoe modifications. On 12/21/18, she underwent bilateral platelet-rich plasma injections to the plantar fascia medial and central bands. There is a lack of large volume, long-term, peer-reviewed outcome studies to support this treatment in this patients case. Therefore, injection of platelet-rich plasma performed on 12/21/18 was not likely to have been more effective than other treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 50-year-old female enrollee has requested reimbursement for residential substance abuse rehabilitation services provided from 7/25/14 through 8/23/14. 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 upon review of the submitted documentation the medical necessity of residential treatment services provided from 7/25/14 through 8/23/14 has not been established. In this case, the patient was motivated to seek alternative options to treatment in order to reduce her recently prescribed sedating medications. According to the records, although the relationship dynamics were strained, the patient had a safe residence and supportive family. Her physical examination upon presentation was reassuring and her provider determined that detoxification was not necessary. She was seeing a psychiatrist in the community. The patient had no history of suicidality and the diagnosis of bipolar illness was not substantiated in the records provided. Further, the records do not demonstrate the patient had failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program, during the episode of illness. This is significant in this case for two reasons: first, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Based upon the submitted records and accepted principles of psychiatric practice, the residential rehabilitation services at issue were not medically necessary for treatment of the patients behavioral health condition.  The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 62-year-old male enrollee has requested authorization and coverage for proton beam therapy. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  service  is 
investigational for the treatment of the enrollees prostate cancer. The physician reviewer found 
that most current medical literature regarding the treatment of localized prostate cancer is on 
the use of photon-based radiation treatment. The benefits of proton therapy in prostate cancer 
treatment are still controversial due to a lack of high-level evidence showing its relative benefits 
in improving patient quality of life, reducing treatment toxicity, and improving outcomes. Proton 
therapy may potentially reduce the radiation dose to organs at risk and improve radiation dose 
homogeneity. The risk of secondary malignancy is likely lower in patients with prostate cancer 
treated with proton therapy compared to those treated with photon therapy. On the other hand, 
disadvantages  in  using  proton  therapy  include  dose  distribution  and  conformality  and 
uncertainties in the radiobiologic effectiveness in treating patients with prostate cancer. While 
there are no randomized phase III trials comparing the toxicity profile and effectiveness of proton 
therapy versus photon therapy in the treatment of prostate cancer, there are several published 
prospective and retrospective studies with long-term follow-up data showing the safety and 
efficacy of proton therapy in prostate cancer. In this clinical setting though, a combined modality 
using brachytherapy and external beam radiation therapy (EBRT) is likely to provide the patient 
with superior outcomes in terms of biochemical progression-free survival. Therefore, proton 
beam therapy is not likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 47-year-old female enrollee has requested authorization and coverage for FreeStyle Libre continuous glucose monitor. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees diabetes. The physician reviewer found that according to the American Association of Clinical Endocrinologists and American College of Endocrinology consensus statement, real-time continuous glucose monitors should be available to all insulin-using patients regardless of diabetes type. Patients with type 2 diabetes who use antihyperglycemic agents other than insulin might also benefit from continuous glucose monitors, but the evidence base is inadequate to make a strong recommendation. The consensus statement noted the primary purpose of continuous glucose monitors is to identify glucose patterns, hypoglycemia, and hyperglycemia. Patients using personal continuous glucose monitors should use real-time data to prevent and/or treat hypoglycemia and hyperglycemic excursions, as well as retrospectively to adjust their treatment regimens. As this patient is currently using insulin, she meets these criteria. The medical evidence supports the requested device in this setting. Thus, the FreeStyle Libre continuous glucose monitor is medically necessary for the treatment of this patient. Therefore, the requested device 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 
This patient is a 44-year-old female who presented to her provider on 3/12/21. The records noted that is 5 feet 2 inches tall and weighed 165.7 pounds, resulting in a body mass index of 30.31 kg/m2. The patient has requested authorization and coverage for laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and Roux-en-Y gastroenterostomy. The Health Insurer has denied this request and reported that the requested services are 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 fails to demonstrate the medical necessity of the requested services. Although the patient may benefit from conversion to gastric bypass for treatment of severe refractory gastroesophageal reflux disease in the setting of a prior Lap-band with hiatal hernia and esophageal dysmotility, additional documentation is needed. The poor esophageal motility would make her a poor candidate for either a LINX or standard Nissen fundoplication. However, the patient should still undergo a comprehensive multidisciplinary evaluation for the subsequent dietary and lifestyle changes unique to gastric bypass regardless of the primary indication. Although a brief dietary note was provided with standard dietary handouts, the records do not document a behavioral evaluation. Therefore, a multidisciplinary evaluation has not been completed. Therefore, the requested laparoscopy, surgical, gastric restrictive procedure, with gastric bypass and Roux-en-Y gastroenterostomy is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 54-year-old male enrollee has requested reimbursement for radiofrequency neurolysis performed on 4/08/16.  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 there is sufficient support for a portion of the services at issue.  In this case, the records indicate that this patient underwent radiofrequency ablation in March 2015 prior to the repeat radiofrequency ablation on 4/08/16.  The patient previously experienced several months of pain reduction following the radiofrequency ablation in March 2015.  Based on the medical evidence, the superior efficacy of radiofrequency ablation at the cervical C7 level has been established.  However, there is a lack of support for radiofrequency ablation performed on thoracic levels T1, T2 and T3.  Boswell and colleagues noted the evidence for pain relief with radiofrequency neurotomy of cervical and lumbar medial branch nerves is moderate for short- and long-term pain relief, and indeterminate for thoracic facet neurotomy. Manchikanti and colleagues noted the evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections.  In sum, radiofrequency neurolysis at the C7 level performed on 4/08/16 was likely to have been more efficacious than other treatment options.  However, the superior efficacy of radiofrequency neurolysis performed on thoracic levels T1, T2 and T3 has not been established.  Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for CPT code 81479 provided on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen level. This helps guide the most appropriate therapy for patients, taking into account their age and comorbidities, because many patients will not require therapy (i.e. surgery or radiation) and may be followed closely instead. The important features to recognize are Gleason score and prostate-specific antigen level, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. The Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). The GPS may help identify patients with very low risk disease that can be followed rather than referred for surgery. The medical evidence supports the services at issue in this clinical setting. Thus, CPT code 81479 provided on 12/21/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 50-year-old female enrollee has requested reimbursement and prospective authorization and coverage for laser treatment (CPT 96920) provided from 1/4/16 and 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 vitiligo. The physician reviewer found the laser treatment (CPT 96920) provided from 1/4/16 and forward was and is medically necessary for treatment of the patients medical condition. According to Nicolaidou and colleagues Vitiligo is a common and chronic disease with a great impact on patients quality of life. Phototherapy with narrowband ultraviolet B radiation and excimer laser are two treatment modalities that are used increasingly for the management of the disease with variable results. Treatment with the excimer is the standard of care in this clinical setting and is supported as a first-line treatment for vitiligo (Grimes). Based on the support in the peer-reviewed literature, the services at issue have been established as medically necessary for treatment of the patients vitiligo. Therefore, the services at issue were and are 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 56-year-old male enrollee has requested authorization and coverage for proton treatment. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees tumor of the hypopharynx. The physician reviewer found Currently, that there is a lack of clinical data in the medical literature to indicate the superior efficacy of the requested services when compared to conventional treatment options. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT).  A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton therapy compared to photon therapy for head and neck cancer. Also, the ASTRO emerging technology committee report on proton therapy specifically states that there is insufficient data to recommend proton beam therapy for routine head and neck radiation therapy outside of clinical trials, (Allen, et al). Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer.  The patients previous history of treatment with radioactive iodine does not preclude the use of standard treatment with photons. Therefore, proton therapy is not likely to be more effective than standard therapy in the treatment of this patients medical condition. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 36-year-old female enrollee has requested reimbursement for reduction mammoplasty performed on 7/28/16. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees macromastia. The physician reviewer found that according to the patients letter, her complaints included neck, shoulder and back pain due to her large breasts. These are the typical complaints of women with macromastia. However, this patients records do not support the medical necessity of reduction mammoplasty. There were no photographs provided for review and the records do not include any supporting documentation from the patients primary care provider that confirms the presence of disabling musculoskeletal symptoms from macromastia. An operative or pathology report documenting the weight of the reduction was also not provided. A work-up for other possible causes of her symptoms is not documented, and she has not reportedly been evaluated by a musculoskeletal specialist. The records do not include any documentation that attempts at medical treatment for chronic musculoskeletal pain such as chiropractic care, physical therapy, analgesics or support bras. In this case, only the plastic surgeons notes describe musculoskeletal pain. Confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence of severe breast hypertrophy or a history of frequent primary care physician visits for musculoskeletal symptoms is necessary to support the history provided by the plastic surgeon. All told, the reduction mammoplasty performed on 7/28/16 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was 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 1


A 41-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 11/06/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  All told, breast tomosynthesis performed on 11/06/15 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that in the case under discussion, the patient was being evaluated for anemia. Part of the differential is nutritional deficiency in folate or vitamin B12. Discriminating between these two deficiencies is possible by analyzing homocysteine and methylmalonic acid levels. Homocysteine levels are elevated in folate deficiency since methyl-tetrahydrofolate is a methyl donor to cobalamin. In contrast, folate is not required for the conversion of methylmalonyl-CoA to succinyl-CoA where S-adenosylcobalamin is the cofactor (Allen, et al; Tefferi). Given these findings, the homocysteine testing provided on 9/5/14 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, I have determined 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 25-year-old transgender male enrollee has requested authorization and coverage for total hysterectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The Health Insurer noted that the requested services are not medically necessary because he needs to be living as male for two years and on hormones for one year before surgery. World Professional Association for Transgender Health (WPATH) has no requirements for social transition before hysterectomy. There is a one year requirement before reconstructive genital surgery, such as phalloplasty or metoidioplasty, but not for hysterectomy. Per WPATH, social transition is not required before hysterectomy. WPATH recommends one year of hormones before hysterectomy, unless this is not clinically indicated. The decision that this is clinically indicated before one year lies with the patients treatment team, which recommends the surgery. WPATH lists 12 continuous months of hormone therapy as appropriate to the patients gender goals (unless hormones are not clinically indicated for the individual). This provides flexibility for the treatment team to decide on the appropriate hormone treatment regimen before hysterectomy. WPATH noted that hysterectomy is one of the medically necessary treatments for gender dysphoria. There is sufficient support for the requested services in this clinical setting. Therefore, the requested hysterectomy is medically necessary for the treatment of this patient.