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

Summary Reviewer 3

A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the requested device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although the patient meets certain clinical criteria for implantation of a hypoglossal nerve stimulator, the records do not document that the patient has tried and failed other potential surgical options such as uvulopalatopharyngoplasty (UPPP). In addition, a record of the patients complete physical examination is not included and the clinical status of the patients tonsils are unknown. For the reasons provided, the implanted upper airway stimulation device (Inspire) device 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 device 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: Upheld

Summary Reviewer 1

A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that there is a lack of support in the medical literature for the services at issue in this patients case. The test claims to determine risk of recurrence for early melanoma. However, there is a lack of data to support using adjuvant therapy in similar patients based on risk of recurrence. Adjuvant therapy is based on stage and not on the risk of recurrence as determined by this test. Moreover, the literature does not support a therapeutic advantage of this test over the standard options since this test is not designed to change or alter therapy nor alter surveillance regardless of risk. Furthermore, prospective randomized data for determination of recurrence is lacking in this test. All told, the gene test (gene expression profiling) performed on 9/20/16 was not likely to have been more beneficial than the established alternatives available for the evaluation of this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
A 23-year-old female enrollee has requested reimbursement for intraoperative monitoring on 
7/25/22. The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of the right hip. The physician reviewer found that in this case, the patient  is  a  23-year-old  female  with  spastic  quadriparesis  secondary  to  cerebral  palsy  and  spastic 
dislocation  of  right  hip.  Cerebral  palsy  is  a  group  of  permanent  disorders  that  affect  the 
development of movement, causing a limitation of activity. Spastic quadriparesis secondary to 
cerebral palsy occurs when a patient has spasticity and motor difficulties affecting all four 
extremities. There are many complications that can occur in a patient with cerebral palsy, including 
orthopedic disorders such as hip subluxation, dislocation, foot deformities, and scoliosis. In this 
case, the patient had spastic dislocation of the right hip and was treated by orthopedic surgery. 
Surgical  procedures  included  varus  derotational  osteotomy  of  the  right  proximal  femur, 
periacetabular osteotomy, lengthening of the hip adductors and iliopsoas, intraoperative nerve 
monitoring, and peripheral nerve block. Intraoperative nerve monitoring is a technique applied 
during a surgical procedure to continuously evaluate nerve signals to use as an early warning sign 
of nerve injury. There are several types of intraoperative nerve monitoring, including motor evoked 
potentials,  somatosensory  evoked  potentials,  electromyography,  and  anterior  root  muscle 
response. The evidence supporting the use of intraoperative nerve monitoring during surgical 
procedures varies in the medical literature depending on type of surgery. For surgeries that pertain 
to the hip, there is evidence that intraoperative nerve monitoring is effective at helping prevent 
nerve damage, especially in high-risk cases. In this case, given the patients history of cerebral 
palsy and spastic quadriparesis, she is at high-risk for severe deformities. In addition, evidence 
demonstrates the benefit of intraoperative nerve monitoring for surgical procedures of the hip. In 
this clinical setting of a patient is diagnosed with spastic quadriparesis secondary to cerebral palsy 
and spastic dislocation of right hip, intraoperative nerve monitoring is considered standard care. 
Therefore, intraoperative monitoring on 7/25/22 was likely to have been more beneficial for 
treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 63-year-old male with a history of extensive spine surgery, including previous L3-4 laminectomies and foraminotomies as well as an instrumented lumbar fusion at L4-5. The patient has requested authorization and coverage for right L3-L4 foraminotomies.  The physician reviewer found that lumbar foraminotomies have been an accepted surgical treatment strategy for lateral recess/foraminal stenosis for decades. This procedure is well-established for its safety and efficacy. Hu and colleagues recently performed a large retrospective cohort study on patients who underwent primary or repeat foraminotomies to compare their effectiveness. Five hundred and seventy-nine procedures were eligible for evaluation. Using validated outcome measures, the authors observed that primary and repeat foraminotomies have similar successful outcomes. This patientas provider evaluated the patient and ruled out other sources of the patientas pain. He notes dermatomal pain and sensory changes with meaningful weakness that correlates to the patientas progressive imaging changes with at least moderate foraminal stenosis noted on his most recent MRI scan. The patient attended several physical therapy sessions as noted in the records.  The documentation notes that he stopped this as it made his symptoms worse. The evidence supporting the role of physical therapy in the care of lumbar radiculopathy is lacking and of low quality despite the fact that it is one of the most prescribed treatments. In a literature review on the topic of conservative therapies for lumbar radiculopathy, Alentado and colleagues noted that there is not strong evidence to support any particular duration of this treatment. They recommend on the basis of the literature, anything from four to eight weeks. On the basis of extensive review of the records and documentation provided, the requested services are medically necessary. The patient had concordant historical and physical examination findings with the reported imaging studies. He was unable to tolerate physical therapy after attempting it. He had neurological weakness that was documented on examination. Therefore, right L3-L4 foraminotomies are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 24-year-old male enrollee has requested reimbursement for s physiotherapy on 12/7/17 and 12/14/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees arm pain. The physician reviewer found that there documentation provided does not support the medical necessity of the services at issue in this clinical setting. Musicians are at risk for musculoskeletal injury due to overuse and potential underlying factors such as hypermobility (Bird).  Early, specialized assessment, often greatly facilitated by examination during actual play of the musical instrument, is considered essential (Rietveld).  Key diagnostic issues include recognition of posture related problems, osteoarthritis and entrapment neuropathies.  Focused exercise is an appropriate intervention in the setting of some chronic tendinopathies (Childress and Beutler).  In addition, relative rest is an important consideration in the setting of overuse conditions. In the current case, the patient had chronic symptoms affecting his upper limbs. There were posture issues, potential overuse and anxiety issues.  The patient had been undergoing physical therapy for a prolonged period of time, and had maximized the benefit derivable from formal therapy prior to 12/7/17.  Based on the documentation provided, his symptoms were largely correlated with stress/anxiety and relieved by stress reduction interventions more than physical therapy.  The patient was working on general trunk and core exercises at of the time period in question, with no indications that he could not have been doing these basic conditioning and strengthening exercises independently.  He was receiving manual therapy. Formal manual therapy is not proven to be any more effective than self-applied interventions such as using a foam roller, stretching or applying thermal modalities in the long term. Accordingly, physiotherapy provided on 12/7/17 and 12/14/17 were not medically necessary for treatment of this patients medical condition. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A year-old male enrollee has requested reimbursement for inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18. 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 at the time of presentation to the emergency department, the patient reported leg pain with swelling.  He did not complain of chest pain or difficulty breathing, but he was tachycardic and febrile with increased respiratory rate. The laboratory studies were significant for an elevated troponin. Although there was no obvious cardiac ischemia on echocardiogram, the cardiac enzymes were abnormal and the patient was tachycardic. Admission to an acute inpatient level of care with telemetry was medically reasonable from 8/03/18 through 8/05/18. The patient stabilized medically with treatment, including antibiotics and intravenous fluids. There was no evidence of significant electrolyte abnormalities, cardiac ischemia or dysrhythmia as of 8/05/18. Therefore, inpatient hospital stay at telemetry level of care from 8/03/18 through 8/05/18 was medically necessary for the treatment of this patient. The medical records fail to demonstrate the medical necessity of inpatient hospital stay at telemetry level of care from 8/06/18 through 8/09/18.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
A 27-year-old female insured has requested authorization and coverage for Besremi 500 mcg/mL 
syringe. A review of the record indicates the insured is currently pregnant and has a history of 
essential thrombocythemia. The Health Insurer indicates the requested treatment is considered 
investigational for the treatment of the insureds medical condition. Therefore, the Health Insurer 
has denied coverage for the requested treatment. This denial is the subject of this appeal and 
determination.  The  physician  reviewer  found  that  the  essential  thrombocythemia  is  a 
myeloproliferative disorder caused by specific mutations in the hematopoietic stem cells. Essential 
thrombocythemia manifests as a high platelet count, which predisposes patients to abnormal 
clotting.  As  noted  in  the  medical  literature,  there  is  a  large  overlap  between  essential 
thrombocythemia and polycythemia vera both in clinical manifestations and in molecular genetics. 
The mainstay of treatment is the reduction of the platelet count using hydroxyurea, anagrelide, or 
interferon. Pegylated interferon is an alternate formulation of interferon that has less toxicity. 
Current medical evidence shows that pegylated interferon can reduce the platelet counts of 
essential thrombocythemia patients. Since this patient has been able to tolerate treatment with the 
Pegasys formulation, but reports problems with tolerating weekly injections was not tolerated, then 
the Besremi is an excellent next choice (Okikiolu, et al.; Penna). Accordingly, the requested 
Besremi 500 mcg/mL syringe is likely to be more beneficial for the treatment of the patients 
medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 43-year-old female with a history of left upper extremity, lower extremity and trunk pain. The provider reports the patients pain is consistent with complex regional pain syndrome (CRPS), autonomic nervous system dysfunction, and gastrointestinal dysfunction. The patient states that since starting treatment with neuromuscular stimulation therapy, she has begun to regain muscle that was atrophied. She can walk short distances without assistance. A 2/20/18 document from her provider reports that the patient had a left knee immobilizer and then crutches for several months which caused atrophy and leg weakness. On physical examination, there was weakness in her right L4, L5, and S1 myotomes and upper body myotomes in C5, C6 and C7. The provider recommended a system called Advanced Recovery Program which is neuromuscular stimulation therapy. The patient has requested authorization and coverage for neuromuscular stimulation therapy. The Health Insurer has denied this request indicating that the requested equipment is not medically necessary. There is a lack of trials demonstrating clinical benefit with neuromuscular electrical stimulation for chronic pain. Although the records indicate the patient has some weakness in the upper and lower extremity, there is no evidence of muscle atrophy on physical examination documentation. The provider states that a left knee immobilizer caused the patient atrophy. However, a knee immobilizer on the right is not likely to affect all of the unilateral left L4, L5, and S1 myotomes as indicated in the progress note. Additionally, the provider states the patient had leg weakness from using crutches, which does not explain the unilateral weakness. Moreover, there is no progress notes indicating muscle atrophy on a physical examination. Overall, the available documentation does not support the requested neuromuscular stimulation therapy as medically necessary for treatment of this patients medical condition.  Based on the foregoing discussion, 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 

The patient is a 30-year-old female with moderate-severe rheumatoid arthritis. The patient has requested authorization and coverage for Enbrel SureClick. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that according to the 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, in established rheumatoid arthritis, aIf disease activity remains moderate or high despite DMARD monotherapy, the recommendation is to use combination traditional DMARDs or add a tumor necrosis factor inhibitor (TNFi) or a non-TNF biologic or tofacitinib (all choices with or without methotrexate, in no particular order of preference), rather than continuing DMARD monotherapy alone.a In this case, the records document a history of moderate-severe rheumatoid arthritis. In addition, she has failed DMARD therapy. She previously was treated with methotrexate, sulfasalazine and hydroxychloroquine, with uncontrolled disease. It is therefore appropriate to consider TNFi therapy in this case based on the guidelines. She was placed on the TNFi, Humira, which was ineffective. She was then placed on an alternate TNFi, Enbrel SureClick. On 7/29/20, office visit notes indicate that Enbrel SureClick was helping to control rheumatoid arthritis. There is sufficient support for the requested medication in this clinical setting. Therefore, Enbrel SureClick is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 30-year-old female enrollee has requested reimbursement for genetic testing on 4/14/22. The 
Health Insurer has denied this request and reported that the service at issue was investigational for 
the evaluation of cystic fibrosis of the enrollees fetus. The physician reviewer found that while the 
Society for Maternal-Fetal Medicine (SMFM) notes that an ultrasound finding of echogenic bowel 
increases the risk of cystic fibrosis in the fetus to by two to three percent, the full gene sequencing 
at issue in this case was not likely to have been more beneficial than standard screening with either 
limited cystic fibrosis variant panels, consisting of 25 to 150 variants, or expanded mutation panels. 
The  American  College  of  Obstetrics  and  Gynecologists  (ACOG)  reports  regarding  carrier 
screening for genetic conditions that analysis of the cystic fibrosis transmembrane conductance 
regulator (CFTR) gene by deoxyribonucleic acid (DNA) sequencing is not appropriate for routine 
carrier screening. The ACOG further notes that this type of testing generally is reserved for patients 
with cystic fibrosis, patients with negative carrier screening results but a family history of cystic 
fibrosis, especially if family test results are not available, males with congenital bilateral absence 
of the vas deferens, or newborns with a positive newborn screening result when mutation testing 
using the standard 23-mutation panel has a negative result. Therefore, genetic testing on 4/14/22 
was not likely to have been more beneficial for evaluation of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 21-year-old female enrollee has requested reimbursement for the Game Ready system provided on 9/10/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees medical condition. The physician reviewer found the Game Ready cryocompression device provides icing and compression for an extremity after surgery. Although both compression and icing are beneficial for the patient after surgical intervention, there is a lack of evidence in the peer-reviewed literature that the supports use of the Game Ready cryocompression device as more beneficial than standard therapies in this clinical setting. Most of the medical literature suggests benefit for patients after joint replacement surgery. All told, there is a lack of peer-reviewed literature that supports the Game Ready cryocompression device as likely to be more beneficial for this patient than icing and wrapping. 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 42-year-old male with a medical history including obesity, dyslipidemia, and fatty 
liver. The patient has requested authorization and coverage for Wegovy (semaglutide solution 
auto-injector 2.4 mg/0.75 ml). The physician reviewer found that Semaglutide is an antidiabetic 
agent, glucagon-like peptide-1 (GLP-1) receptor agonist.  The initial management of individuals 
who would benefit from weight loss is a comprehensive lifestyle intervention: a combination of 
diet, exercise, and behavioral modification. All patients who would benefit from weight loss 
should receive counseling on diet, exercise, and goals for weight loss.  When a patient with a 
body mass index (BMI) greater than 30 kg/m2 or a BMI of 27-29.9 kg/ms with comorbidities, such 
as hypertension or diabetes mellitus, and has failed to achieve weight loss goals through diet and 
exercise  alone,  a  pharmacologic  therapy  is  suggested.  Wegovy  is  a  brand-named  form  of 
semaglutide that is indicated for chronic management of obesity. It is U.S. Food and Drug 
Administration (FDA) approved for the use as an adjunct to diet and exercise in individuals with 
a BMI greater 30 kg/m2 or for individuals with a BMI greater than 27 kg/m2 and one or more 
weight-associated comorbidity. The initiation of Wegovy is as follows: week 1 through week 4: 
0.25 mg once weekly; week 5 through week 8: 0.5 mg once weekly; week 9 through week 12: 1 
mg once weekly; week 13 through week 16: 1.7 mg once weekly; and week 17 and ongoing 
maintenance dose is 2.4 mg once weekly. Of note, there were discrepancies in the submitted 
documentation. The records noted that the patient has been treated with Wegovy, but the 
submitted prior authorization form indicated that this is a new prescription and does not start 
him at the correct dosage. The provider letter appears to be from supporting staff and not truly 
part of the medical records. There are assumptions that the author is making that are not well-
documented in the medical record. The submitted documentation fails to support that the 
medication  is  being  prescribed  correctly  and  monitored  effectively.  Additionally,  the 
documentation does not indicate that the patient is participating in an appropriate diet/exercise 
plan. Therefore, Wegovy (semaglutide solution auto-injector 2.4 mg/0.75 ml) is not medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. 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 this patient presented with a transient ischemic attack in the setting of reported hypertensive urgency. There are no other verified transient ischemic attacks and a reportedly normal head computed tomography (CT) scan. In patients with transient ischemic attacks and patent foramen ovales, transcatheter closure has been demonstrated to be of mild benefit only in younger patients without another potential source of transient ischemic attack, such as hypertensive urgency, and mainly in patients with transient ischemic attacks despite antiplatelet medication. This patient does not fit those criteria since there is another potential source and his age is greater than 60. In sum, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.