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

Summary Reviewer 


A 34-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health inpatient services provided from 6/30/16 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 depression, substance dependence, and suicidality. The physician reviewer found that in the medical literature, services are custodial when they do not require continued administration by trained medical personnel. Sharfstein noted that crisis stabilization, safety, and a focus on rapid discharge are the critical components of the acute inpatient stay. Although this patient indicated after detoxification that he would attempt suicide via jumping off a bridge if he were discharged from acute hospital level of care, by 6/30/16 the patient no longer endorsed suicidal ideation and was in no acute distress. The statements made by the patient indicate that he has insight into his substance use disorder and longstanding family conflict. Overall, there is a lack of documentation that the patients needs cannot be met in a less restrictive treatment setting. Accordingly, there is a lack of medical necessity for the 24-hour registered nurse on-site and 24-hour physician on-call services provided by acute inpatient hospital level of care from 6/30/16 forward for treatment of this patients medical condition. Based on these findings, 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 44-year-old female enrollee has requested authorization and coverage for HP Acthar Gel 80. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. There is a lack of randomized, double-blinded, placebo-controlled studies in support of Acthar for systemic lupus erythematosus. The current evidence consists of small reports. The study by Levine involved a small group of patients with myositis that responded favorably to Acthar. Although this is encouraging, it is not conclusive in that group of patients. The study by Fiechtner and Montroy included just ten patients, and patients were followed only over a 28-day period. This is an inadequate study to base approval of this medication for this patient. Pegrams study is inadequate, as it was a retrospective evaluation of four woman with lupus who were followed for 1.5, 3.5, 6 and 9 months each. At this time, the medical necessity of the requested medication has not been established. Therefore, HP Acthar Gel 80 unit/ml vial is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for an Anser ADA test performed on 5/12/15. The Health Insurer has denied this request indicating that the procedure at issue was considered investigational for evaluation of the enrollees Crohns disease with ileostomy. The physician reviewer found that 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 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 at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. The Karmiris study found no direct relationship between trough serum adalimumab concentration or anti-adalimumab antibody and short-term treatment efficacy (Karmiris, et al). 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. Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management (Lichtenstein, et al). A review article reported that the available data do not allow final conclusions about the relevance of anti-adalimumab antibodies to the clinical efficacy of adalimumab, and another concluded that prospective controlled trials are direly needed to investigate the optimal tailored management in individual patients who lose response (Assche, et al; Yanai, et al). All told, the Anser ADA performed on 5/12/15 was investigational for the purpose of evaluating this patients medical condition.
For the reasons set forth above, the procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer


The patient is a 48-year-old female who had previously undergone augmentation mammoplasty for apparent aesthetic concerns. She is noted to have evidence of bilateral silicone implant rupture, as documented on radiographic studies and confirmed on the operative report dated 12/11/17. The patient has requested reimbursement for removal of mammary implant material provided on 12/11/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The submitted documentation supports the medical necessity of the services at issue. The records document ruptured silicone implant. The significance of a ruptured silicone implant is not known. Given this uncertainty, the U.S. Food and Drug Administration (FDA) recommends removal of ruptured silicone implants. It is well-known that free silicone can travel to lymph nodes and cause painful nodules. Thus, the services at issue were medically indicated. The fact that the original surgery was done for cosmetic reasons does not change the functional concern associated with ruptured silicone implants. All told, removal of mammary implant material provided on 12/11/17 was medically necessary of the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 66-year-old male enrollee has requested reimbursement for LINX procedure/device performed on 7/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has history of belching and heartburn. The physician reviewer found that in this patients case, he has gastroesophageal reflux disease (GERD) based on pH recording. However, the records indicate that his heartburn has benefited, to a significant degree, from acid suppression treatment and as such cannot be considered medically refractory to acid blocker drugs. Moreover, the patients issues with belching was not eliminated upon LINX placement. Therefore, in this patients case, the LINX procedure/device was not likely to be more beneficial than any available standard therapy for treatment of the patients medical condition. 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 57-year-old female with a history of chronic back pain, anxiety and hypertension. She presented to her primary care provider on 12/21/20 for a physical examination. The physician reviewer found that the clinical manifestations of vitamin D deficiency depend upon the severity and duration of the deficiency. The majority of patients with moderate to mild vitamin D deficiency are asymptomatic. With severe vitamin D deficiency, there can be hypocalcemia, which leads to bone disorders. Patient groups who are at risk for vitamin D insufficiency include those who have dark skin or are obese, those taking medications that accelerate the metabolism of vitamin D, hospitalized or institutionalized people, and patients who have limited effective sun exposure. Other people at high risk include those with osteoporosis or malabsorption, including inflammatory bowel disease and celiac disease. Screening of the general population is not recommended. Normal-risk adults do not need assessment. In this case, the records did not document any chronic medical conditions that would cause vitamin D deficiency or symptoms associated with vitamin D deficiency. There is a lack of support for the services at issue in this clinical setting. Therefore, vitamin D testing performed on 12/21/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 32-year-old female enrollee has requested reimbursement for laboratory testing performed on 6/26/19. 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 there is extensive literature supporting the services at issue in this clinical setting. The factor V mutation has the potential to induce hypercoagulopathy in the right environment, such as a long airplane flight or automobile trip, as in this patients case. Importantly, prothrombin G20210A mutation adds to this risk, such that compound heterozygous patients can have up to 20-fold increased odds of developing deep vein thrombosis. The testing performed was likely to directly alter the treatment recommendation. If this patient was found to be a carrier of multiple mutations predisposing to thrombosis, then a recurrent thrombotic event could be prevented with drugs and/or activity. Thus, laboratory testing performed on 6/26/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 45-year-old female who has been followed for a diagnosis of polymyositis with onset in early 2017. In a letter dated 7/17/20, the provider noted that the patientas disease has been difficult to control due to a poor response to medications and poor tolerance. She is currently on prednisone and intravenous immunoglobulin. The physician reviewer found that the idiopathic inflammatory myopathies (IIM) are a heterogeneous group of acquired disorders characterized by chronic inflammation of striated muscle leading to predominantly proximal muscle weakness. The most common subsets of IIM include adult polymyositis (PM), adult and juvenile dermatomyositis (DM), myositis in overlap with cancer or another connective tissue disease and inclusion body myositis (IBM). The general clinical consensus among physicians is to use high-dose corticosteroid therapy as the first-line option in patients with myositis. However, several patients discontinue steroid treatment early because of a lack of improvement and/or adverse events. In patients with myositis resistant to conventional treatment, the anti-CD20 monoclonal antibody rituximab is a potential treatment option. 
The benefit of rituximab was demonstrated in the study by Oddis and colleagues. This study included 200 patients with polymyositis, dermatomyositis, or juvenile dermatomyositis not controlled by corticosteroids and other immunosuppressive agents. Patients were randomized to receive different regimens of rituximab (two infusions at baseline or 8 weeks later). Although the group treated with rituximab at onset did not improve significantly earlier than the group treated after a delay of 8 weeks (the primary endpoint), the majority of patients (83%) responded to rituximab treatment, and a significant steroid-sparing effect was reported. Fasano and colleagues reviewed 48 studies of refractory myositis patients treated with rituximab. They identified 458 patients with myositis treated with rituximab and found a rate of response to rituximab of 78.3%. They concluded that rituximab can play a role in the management of patients with myositis. In this case, the patient has polymyositis which has been poorly responsive to standard therapy. Based on the studies above, a majority of patients respond favorably to Rituxan and a significant steroid-sparing effect is noted. Therefore, the requested medication is medically necessary for the treatment of the patientas medical condition.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 55-year-old female who presented to her provider on 9/12/22. The records noted a 
history  of  post-menopausal  osteoporosis.  The  patient  has  requested  reimbursement  for 
complement antigen on 9/13/22. The Health Insurer has denied this request and reported that the 
service at issue was not medically necessary for the evaluation of this patient. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the service at issue. In this case, the blood work 
at issue was an array of tests designed to screen for a variety of autoimmune and inflammatory 
conditions such as lupus, rheumatoid arthritis, celiac disease, or autoimmune thyroiditis, that could 
present with inflammation of the small joints, the PIP and MCP, of the hand. The records note that 
the provider ordered complement levels, C3 and C4, double stranded deoxyribonucleic acid 
(dsDNA), and a variety of cytoplasmic antigens such as RNP and Smith antigens to complete a 
workup for systemic lupus. Given that these tests were required to rule out a diagnosis of systemic 
lupus erythematosus, the service at issue was medically indicated. Therefore, complement antigen 
on 9/13/22 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for inpatient services provided on 2/25/19. 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 the submitted documentation supports the medical necessity of the services at issue. This patient symptomatically improved after treatment in the emergency department with morphine. He was hemodynamically stable, although bleeding from displaced rib fractures can be delayed. Per the medical evidence, three or more traumatic rib fractures meets criteria for an acute inpatient level of care. This patient had a traumatic motorcycle injury resulting in five rib fractures on the left and a hemopneumothorax. He had a history of hypertension and pre-diabetes. Due to his advanced age, medical comorbidities and the nature of the injury, acute inpatient level of care was appropriate. Therefore, inpatient services provided on 2/25/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX reflux management system lower esophageal sphincter augmentation is 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 service is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1
The parent of a 17-year-old female enrollee has requested reimbursement for autonomic testing performed on 8/24/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees chronic fatigue and presumed postural orthostatic tachycardia syndrome (POTS).   The physician reviewer found automatic testing encompasses multiple tests to evaluation autonomic function. Goals include evaluating the severity and distribution of autonomic function, diagnosing limited autonomic neuropathy, diagnosing and evaluating orthostatic intolerance, monitoring the course of dysautonomia, and monitoring response to treatment. Evaluations include tests of sudomotor function, tests of cardiovagal function, and tests of adrenergic function. The role of autonomic testing is to increase sensitivity and specificity in the detection of autonomic failure. The two work hand in glove and each enhances the other (Low, et al). 
POTS is defined by a constellation of symptoms, including increase in heart rate of 30 beats per minute (40 for children and teenagers) from supine to standing, worsening symptoms with standing, symptoms lasting more than six months, and absence of other causes of orthostasis. Activities of daily living may exacerbate symptoms, with resulting fatigue. Cardiac complaints are common, such as chest pain and lightheadedness, as are non-cardiac complaints such as nausea, headache, poor sleep, and fatigue. Memory may be affected, as well as attention. Based on this patients clinical presentation, the differential diagnosis of chronic fatigue versus POTS, and need to establish an appropriate recovery plan, autonomic testing was appropriate. For these reasons, the autonomic testing performed on 8/24/15 was likely to be more beneficial for evaluation of the patients medical condition than any other available testing. 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 30-year-old female enrollee has requested reimbursement for gene expression profiling performed on 6/29/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found the Decision Dx melanoma assay examines genes for certain markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy in thin melanomas. However, the patients treatment would not likely change based on the results of the exam. There is a lack of medical literature to support its use in patients with thin melanomas to effect health outcomes. Given the lack of published data to support the use of gene expression profiling, the testing performed on 6/29/16 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 38-year-old male enrollee has requested authorization and coverage for cardiac resynchronization therapy. The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a history of sarcoidosis and myocardial involvement. The physician reviewer found that in patients with cardiac sarcoidosis and ejection fraction greater than 35% who have an indication for pacemaker placement, it is reasonable to implant a defibrillator if meaningful survival of greater than one year is expected, such as with this patient.  Since 2:1 atrioventricular block is continuous in this case, the patient will be right ventricular paced about 50% of the time once a pacemaker has been placed, raising a concern for chronic right ventricular pacing induced left ventricular dysfunction. There is some data to demonstrate worsening left ventricular dysfunction as a result of chronic right ventricular pacing, but only in patients with a history of heart failure and ejection fraction less than or equal to 50%, neither of which this patient has. Therefore, given this patients ejection fraction and no documented heart failure, biventricular pacing is not medically necessary. Thus, cardiac resynchronization therapy is not medically necessary for the treatment of this patient. Therefore, the requested services 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 1


A 63-year-old female enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) performed on 3/14/16.   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 the current medical evidence supports the services at issue in this patients case.  This patient has a very strong family history of breast cancer with a lifetime risk of 26.4%.  Mammography is a first-line screening tool for breast cancer, but the technique has well-known limitations.  In a patient with a lifetime risk exceeding 20-25%, the American Cancer Society has recommended annual MRI exams as an adjunct to mammography due to the increased sensitivity in detecting early cancer.  In sum, MRI of the breasts performed on 3/14/16 was likely to have been superior over 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.