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

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for mental health partial hospitalization program services provided from 5/12/15 through 9/9/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the services at issue were medically necessary for treatment of the patients medical condition. The documentation submitted for review supports placement at the partial hospitalization program level of care. The records document consistent instability of blood pressure, she was also reported to have black outs, lightheadedness and periods of unstable heart rate. The patient exhibited alterations in her weight with two peaks and two troughs in her weights over time which shows that gains she had made were lost and needed to be readdressed. She continued to have emotional instability particularly when battling her ability to feed herself. For these, a lower level of care could have potentially been dangerous for her. Thus, mental health partial hospitalization program services provided from 5/12/15 through 9/9/15 was medically necessary for treatment of the patients behavioral health condition. 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: Overturned

Summary Reviewer 2

A 44-year-old female enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan of parathyroid gland provided on 7/19/16. The Health Plan has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees hyperparathyroidism. The physician reviewer found that in the medical literature, Eslamy and Ziessman noted that the clinical diagnosis of primary hyperparathyroidism is based largely on serum laboratory test results, as patients often are asymptomatic. Given that approximately 90% of cases are due to a single parathyroid adenoma, the procedure of choice is the selective surgical excision of the hyperfunctioning parathyroid gland after its preoperative identification and localization at radiologic imaging. The authors noted that SPECT, when combined with CT, is particularly helpful for preoperative localization: The three-dimensional functional information from SPECT is fused with the anatomic information obtained from CT. In addition, knowledge of the anatomy and embryologic development of the parathyroid glands and the pathophysiology of primary hyperparathyroidism aid in the identification and localization of hyperfunctioning glands. In this case, the patient presented with a diagnosis of primary hyperparathyroidism complicated by the presence of thyroid nodules. In this clinical setting, the minimally invasive parathyroidectomy procedure is the standard of care. Medical literature supports the use of SPECT/CT scan for the preoperative localization of the tumor. As such, the SPECT scan of parathyroid gland provided on 7/19/16 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, the diagnostic procedure 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 3

A 42-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/29/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees melanoma. 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 high depth of invasion, 0.76 to 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, DecisionDx-Melanoma testing performed on 8/29/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 76-year-old male enrollee has requested reimbursement for the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees stage II colon cancer. The physician reviewer found that per the National Comprehensive Cancer Network (NCC) guidelines, there is insufficient data to recommend multi gene assay panels including Oncotype DX Colon Cancer Assay for determination of need of chemotherapy. The Oncotype DX Colon Cancer Assay has not been demonstrated to predict the response to oxaloplatin based chemotherapy and thus is not indicated for this patient with stage II colon cancer. Given these findings, the Oncotype DX Colon Cancer Assay (CPT 81525) performed on 10/25/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer

The patient is a 49-year-old female with a history of Grovers disease.  She has tried and failed therapy with topical steroids and prednisone. She has had success with a three-month trial of isotretinoin. The patient has requested coverage for Myorisan (isotretinoin) 40 mg 60/30 days. The Health Insurer has denied this request and reported that the requested medication is 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 requested medication. Grovers disease is a persistent inflammatory condition of the skin which can be associated with severe pruritus.  There are no U.S. Food and Drug Administration (FDA) approved therapies for this condition due to its rarity. There is some evidence in the medical literature that systemic retinoids may be helpful for this condition. This patient has tried and found benefit with isotretinoin. Given the lack of alternatives, there is sufficient support for the requested medication in this patients case. Thus, Myorisan (isotretinoin) 40 mg 60/30 days 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 59-year-old female who has requested reimbursement for a cold cap for chemotherapy provided from 1/02/19 through 12/31/19.  The patient has requested reimbursement for a cold cap for chemotherapy. The Health Insurer has denied this request and reported that the device at issue was not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.The physician reviewer found that there is sufficient support for the device at issue in this clinical setting. Chemotherapy-induced alopecia is a symptom that results from the treatment of cancer. It is what many cancer patients state makes them feel like they have cancer and affects quality of life. In this patients case, use of the cold cap was supported by her provider. There are no other acceptable alternatives. U.S. Food and Drug Administration (FDA) clearance of scalp cooling devices has been extended to cover patients with all solid tumors, and extensive data exists to support this use. More than 60 percent of patients receiving taxanes will develop grade 1 alopecia. Scalp hypothermia has been used in more than 30 countries to prevent or reduce chemotherapy-induced alopecia, with variable success reported depending on the specific cooling device and type of chemotherapy. However, use with taxanes has been efficacious. Scalp cooling is now listed as an option for alopecia prevention in the National Comprehensive Cancer Network (NCCN) guidelines for breast cancer. Therefore, the cold cap for chemotherapy was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested reimbursement for a tonsillectomy and adenoidectomy performed on 10/27/15. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees recurrent strep throat. The physician reviewer found that this case involves justification of the surgical intervention performed on the patient because of recurring episodes of acute pharyngitis and tonsillitis with positive cultures and requirements for antibiotic therapy. Tonsillectomy and adenoidectomy is a well-recognized surgical procedure for the treatment of patients with episodes of recurring acute pharyngitis and tonsillitis poorly controlled with outpatient antibiotic therapies. Multiple case studies have demonstrated that surgical removal of the infected source of the Streptococcal infections by removal of the tonsils and adenoids leads to improvement and reduction of the episodes of these acute infections (Baugh, et al). Clinical studies also indicate that patients who have multiple bouts of Streptococcus positive cultures, such as the patient in this clinical scenario, benefit from surgery to reduce the recurrence of these episodes (Burton, et al). This patient had clear documentation of recurrent episodes of culture positive pharyngitis and tonsillitis. Therefore, the tonsillectomy and adenoidectomy performed on 10/27/15 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 33-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/30/15. 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 the Anser IFX test was ordered to direct the use of infliximab in this patient with Crohns disease. However, the use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Based on the clinical literature, the services at issue were likely to be more beneficial for treatment of the patients medical condition than standard management.  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: Upheld

Summary Reviewer 3


A 33-year-old female enrollee has requested reimbursement for homocysteine testing, Factor V Leiden genetic testing and methylenetetrahydrofolate reductase (MTHFR) performed on 8/7/15. The Health Insurer has denied this request indicating that the services at were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) Bulletin states Testing for inherited thrombophilias in women who have experienced recurrent fetal loss or placental abruption is not recommended because it is unclear if anticoagulation therapy reduces recurrence.  There is insufficient evidence to either screen for or treat women with inherited thrombophilias and obstetric histories that include complications such as fetal growth restriction or preeclampsia. Because of the lack of association between either heterozygosity or homozygosity for the MTHFR C677T polymorphism and any negative pregnancy outcomes, including any increased risk for venous thromboembolism, screening with either MTHFR mutation analyses or fasting homocysteine levels is not recommended.  Moreover, thus, there was no medical justification for Factor V Leiden genetic testing and MTHFR for diagnosis and treatment of the patients medical condition.  The testing at issue 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 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 2

A 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. 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 there is sufficient support for a portion of the requested services in this patients case. Providers often do not schedule patients for ablation of all of their refluxing superficial veins at once. Rather, they treat the veins most likely to help based on the ultrasound and the clinical findings and reevaluate the patient. It may not be indicated to treat all of the refluxing superficial veins if the patient is no longer symptomatic after the initial vein is treated. Thus, the treatment of the great saphenous vein or short saphenous vein first, followed by re-evaluation is appropriate. The plan to treat them all regardless of how the patient responds is not supported by the literature or guidelines. Thus, the medical evidence does not support second ablations for each leg until the patient is reevaluated following the initial treatments. Therefore, a portion of the requested foam sclerosant/endovenous ablation is likely to be more effective than other treatment options. Specifically, the superior efficacy of the second ablations for each leg has not been established.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 25-year-old female enrollee has requested reimbursement for residential psychiatric treatment from 10/30/18 through 11/03/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. By 10/30/18, the patient was not actively suicidal or homicidal. She was cognitively intact and was able to perform activities of daily living.  She was not actively psychotic or manic. The endorsement of ongoing passive suicidal thoughts (without intent) appears to be her baseline according to history provided, and no longer required monitoring on a 24/7 basis. She had continuing posttraumatic stress disorder and depressive symptoms, although this did not require 24/7 monitoring. She did not have comorbid medical conditions requiring care in a residential setting. Her medication management and any changes therein could have been performed in an ambulatory setting. She was medication compliant, cooperative, and engaged in all aspects of her treatment. She had support systems in place. Her continued treatment for depression, posttraumatic stress disorder, and any other issues, could have been safely performed at a lower level of care, including partial hospitalization program level of care. Thus, residential psychiatric treatment from 10/30/18 through 11/03/18 was not medically necessary for the treatment of this patient. 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: Upheld

Summary Reviewer  
 
The  patient  is  a  14-year-old  male  who  was  diagnosed  with  eosinophilic  esophagitis  after 
presenting  with  intermittent  episodes  of  food  impaction  and  vomiting.  The  provider  has 
recommended treatment with Dupixent. The physician reviewer found that on review of the 
available records, this patient presents with a diagnosis of eosinophilic esophagitis. The patients 
provider has recommended treatment with Dupixent. The U.S. Food and Drug Administration 
(FDA) has approved Dupixent for the treatment of for adolescents and adults with refractory 
eosinophilic esophagitis. Gutierrez-Junquera and colleagues reported on a prospective study 
evaluating proton pump inhibitor (PPI) treatment in young patients with eosinophilic esophagitis. 
The authors found that PPI therapy led to histologic remission in approximately 50% of the young 
patients studied. Oliva and colleagues performed a recent registry-based longitudinal study that 
found a 30% response rate in children age 10 years and older. There is evidence that patients 
with fibrostenotic disease or more severe endoscopic findings are less likely to respond to PPI 
than those with an inflammatory phenotype or milder endoscopic findings. The correspondence 
from  this  patients  provider  described  a  concern  for  a  fibrostenotic  phenotype.  However, 
approxiatemly  30%  of  patients  with  fibrostenotic  phenotype  have  been  found  to  achieve 
remission with PPI therapy. Overall, the patient has a 30-50% likelihood of histologic response to 
oral treatment with PPI. Thus, trial of a PPI is indicated prior to consideration for treatment with 
Dupixent. With regard to the providers concern about the patients growth, a review of the 
enclosed growth chart does not include a height-for-age or body mass index (BMI)-for-age chart 
to further assess this situation. Accordingly, the requested Dupixent Injection 300/3 mL is not 
medically necessary for treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 40-year-old female enrollee has requested reimbursement for the Genecept Assay provided by Genomind, Inc. on 2/24/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees major depressive disorder. The physician reviewer found that in this patients clinical scenario, there is a lack of clinical data provided to support an indication for genetic testing. Notably absent was documentation of the longitudinal illness burden and extent of impairment, family history, psychosocial stressors and medical comorbidities. Moreover, the provider did not include specific information regarding prior interventions used to treat the patients depression. Without the review of the specific type, setting and duration of psychotherapies, the treatment parameters and outcome of the TMS therapy, or the selection, dosing and length of previous psychotropic medication trials, it cannot be determined that the patient had exhausted standard treatments available to treat her condition. Given these findings, the Genecept Assay provided by Genomind, Inc. on 2/24/16 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing for bacterial vaginosis provided on 5/09/19. 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 support for the services at issue in this clinical setting. Patients with vaginitis can be evaluated and treated with an examination, microscopy and/or cultures depending on the patients symptoms and findings. The exact process depends on the provider and the resources available at that particular office. In this case, the patient presented with a complaint of vaginal odor with no clear etiology on examination. In this setting, cultures can be helpful to determine if there is an infectious cause. It was reasonable that she was evaluated with the SureSwab, especially when no clear cause was found on examination. In sum, polymerase chain reaction (PCR) testing for bacterial vaginosis performed on 5/09/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested authorization and coverage for Nutropin AQ. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. The physician reviewer found the requested medication is not medically necessary for treatment of the patients medical condition. The patient has idiopathic short stature, but she is more than two years post menarche, and she is past the peak of her pubertal growth spurt and her epiphyses are close to being fused. Thus, she is not a candidate for growth hormone therapy to augment height. As such, Nutropin AQ has not been established as medically necessary for treatment of the patients medical condition.  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: Overturned

Summary Reviewer 3

A 64-year-old male enrollee has requested reimbursement for PET scan performed on 8/31/18. 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 complete staging of colorectal cancer is necessary to determine a patients treatment strategy. Imaging is utilized to evaluate for the presence of distant metastases, as this will impact management. Positron emission tomography/computed tomography (PET/CT) scan is most commonly used to evaluate for nodal and distant metastatic disease and has a sensitivity of approximately 89% and specificity of 64% in this setting. PET/CT can also exclude additional sites of metastases aside from more common pulmonary and hepatic metastases. In this case, PET/CT was performed prior to initiating chemotherapy to assess for metastatic disease. Thus, PET scan performed on 8/31/18 was likely to have been more effective than other methods of evaluating this patient.