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

Summary Reviewer 3

An 81-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/27/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for 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, 0.76-1.0 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 for melanoma 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 2/27/18 was not likely to have been of greater benefit than other methods of evaluating 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a five-year-old female with a medical history significant for torticollis. The patients parent has requested reimbursement for one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that blunt abdominal trauma is the third most common cause of pediatric deaths, generally affecting the liver and spleen. Contusions, lacerations, and hematomas are the most likely injuries. Duodenal and pancreatic injuries are not unusual following direct blows to the abdomen or trauma involving bicycle handlebars. Children are at greater risk of renal injuries because of weaker abdominal musculature, decreased perirenal fat, and more flexible thoracic cage. A careful history and physical examination are essential, and when combined with the mechanism of injury, should provide guidance in diagnostic work-up and disposition. However, physical findings can be misleading, and repeated examinations may be necessary to determine need for further diagnostic investigation. Additional information can be gleaned from abdominal ultrasound, with abdominal CT reserved for more symptomatic patients (due to the radiation exposure). Specifically regarding renal trauma, organ preservation is of highest priority. Renal injuries are graded from I to V, with IV and V considered to be high grade and I and II to be low grade. Grade III represents a moderate injury. The trend in management is toward non-operative management, with short- and long-term monitoring for hypertension and persistent bleeding. In this patients case, she presented with stable hemoglobin, indicative of no ongoing blood loss. While it was reasonable to monitor her with serial examinations and laboratory evaluations, she was overall hemodynamically stable, with no evidence of impending circulatory collapse. She did not require acute inpatient admission and could have been safely managed at a lower level of care. Therefore, one-day stay (CPT code 99221) in the pediatric intensive care unit on 5/16/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Euflexxa injections. 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 there is sufficient support for the requested services in this clinical setting. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat injections of viscosupplementation have been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with osteoarthritis of the left knee. She presents with worsening left knee pain and functional mobility impairments. Clinical examination findings are consistent with radiographic evidence of tricompartmental osteoarthritis. She underwent a series of Euflexxa injections in May 2018 and June 2018, with significant pain reduction and improvement in her mobility that lasted six months. She has failed to achieve adequate relief with prior corticosteroid injection, nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and home exercise program. Therefore, the requested Euflexxa injections are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 9/01/16 was likely to have been more effective than other methods of evaluating this patient.  Based upon the information set forth above, the service 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 24-year-old male enrollee has requested reimbursement and prospective authorization and coverage for substance use intensive outpatient services provided from 10/02/18 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 behavioral health conditions. The physician reviewer found that in cases such as this, an evidence-based, objective, instrument such as the American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) is indispensable in determining necessary and appropriate level of care for adults. With regards to risk of harm, the records support a score of 2 due to recent suicidal ideation. In terms of functional status, the records support a score of 2 due to quitting a recent job and conflict with peers. With regards to medical, addictive and psychiatric comorbidity, the records support a score of 2 due to overall medical stability with some mental health issues that appear under good control. In terms of level of stress of the recovery environment, the records support a score of 3 due to a stable living environment but conflict with peers there. With regards to level of support of the recovery environment, the records support a score of 3 due to mention in the records of sober living with few supports. In terms of treatment and recovery history, the records support a score of 3 due to fair recent treatment response in the intensive outpatient program. With regards to engagement and recovery status, the records support a score of 2 due to good cooperation in treatment. Thus, the patient has a composite sore of 17. This score correlates with intensive outpatient program level of care. All told, substance use intensive outpatient services provided from 10/02/18 forward were and are medically necessary for the treatment of this patient. Therefore, the services at issue were and are 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 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The U.S. Food and Drug Administration (FDA) has approved the Watchman device. The Watchman device is an appropriate alternative in patients who are deemed to be at prohibitively high bleeding risk while on long-term anticoagulation, such as is documented with this patient. The requested services are likely to be more beneficial than the alternative of long-term anticoagulation in this patient with a documented high risk of recurrent bleeding. In sum, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be more efficacious than other available treatment options. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment 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 

An 18-year-old male has requested authorization and coverage for Qbrexza. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that according to a recent review published in the American Academy of Dermatology, first-line treatment for primary axially hyperhidrosis is topical antiperspirants. The patient has already tried and failed Drysol, a commonly used first-line antiperspirant. His provider has recommended that the patient continue to use Qbrexa, which is also a topical antiperspirant and is U.S. Food and Drug Administration (FDA) approved for use in axillary hyperhidrosis. Additionally, the International Hyperhidrosis Society considers Qbrexa as first-line treatment for axillary hyperhidrosis. There is sufficient support for the requested medication in this clinical setting. Therefore, Qbrexa is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 19-year-old female enrollee has requested reimbursement for residential treatment provided from 6/19/18 through 8/30/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 4. There was serious risk of harm due to significant impulsivity with poor judgment and insight, manifested by taking cars and driving them without a license or permit, physical aggression towards parents, self-harm, as well as past suicidal ideation. With regard to functional status, the records support a score of 4. The patient had serious functional impairment, due to serious deterioration of interpersonal interactions with consistent conflict or otherwise disrupted interactions with others as well as sporadic school attendance and declining grades. In terms of comorbidity, the records support a score of 3. The patient had multiple mental health concerns. With regard to level of environmental stress, the records support a score of 3. The patient had a moderately stressful environment, due to conflict with parents and difficulty fulfilling expected roles at school and home. In terms of environmental support, the records support a score of 2 due to her parents efforts to arrange and engage with outpatient and then wilderness treatment. With regard to resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment. In terms of treatment acceptance and engagement, the records support a score of 3. The patient was incompletely engaged, due to her initial difficulties accepting responsibility for her role in family conflicts. Therefore, the patient had a composite score of 23. Per CALOCUS, the recommended level of treatment in this case is medically monitored residence-based services. Furthermore, the patient meets criteria for intermediate stay medically monitored residential programs, due to history of impulsivity. Per CALOCUS, at this level of care, the length of stay usually does not exceed 60 days. In this case, the documentation does not support extending the length of stay past the usual 60-day period. The patient not meet criteria for level 5C: long-term medically monitored residence-based services. Therefore, the first two months of wilderness program services, from 6/19/18 through 8/18/18, were medically necessary for treatment of the patients condition. Wilderness program services after that date were not medically necessary. Therefore, that residential treatment provided from 6/19/18 through 8/18/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 50-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 8/03/18. 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 this patient had an early stage melanoma. Per the National Comprehensive Cancer Network guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing performed on 8/03/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a 21-year-old male without a significant past medical history who presented to the 
emergency department with complaints of severe abdominal pain and diarrhea. The patient has 
requested reimbursement for inpatient admission at California Hospital Medical Center Los 
Angeles from 6/26/21  through 6/28/21. The physician reviewer found that the submitted 
documentation fails to demonstrate the medical necessity of the services at issue. Inpatient care 
is necessary when the patients signs, symptoms, and general medical condition can only be 
managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an 
inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient 
setting. In this case, the patients symptoms had improved after treatment in the emergency 
department. He was hemodynamically stable at the time of admission and did not require any 
urgent procedures. The patient was admitted in stable condition and could have been treated at 
a lower level of care. Therefore, inpatient admission at California Hospital Medical Center Los 
Angeles from 6/26/21 through 6/28/21 was not medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15.  The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition.  The physician reviewer found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard. The purpose of HLA-B5701 testing is to determine whether a person is likely to have an allergic reaction to abacavir. Abacavir (Ziagen) is found in several different combination regimens to treat HIV including Epzicom, Trizivir and the popular single tablet regimen Triumeq. HLA-B5701 testing is strongly recommended in most treatment guidelines prior to starting abacavir or an abacavir containing regimen. This patient is highly treatment experienced and is likely to harbor resistance to several classes of HIV medications. It is likely that he may require an abacavir-containing regimen. It will certainly be part of the consideration any time this patient will be changing medications for any reason including simplification, resistance, avoiding nephrotoxicity or bone mineral density decreases. Most HIV providers order HLA-B5701 testing, as part of the initial evaluation of an HIV patient and prefer to have the results on all patients with HIV prior to the time when abacavir is required. Waiting until abacavir is needed prior to sending the test causes delay in treatment in some cases and requires patients to return for additional office visits and blood draws.  The amount of delay may vary widely based on the availability of the testing and ability for patients to access the clinic. While some providers and patients are able to accommodate this, for others it constitutes an unacceptable delay in treatment and undue burden on the patient. These burdens can be severe if testing is not readily available or patients live far from their clinic, have transportation or other access issues. For this reason, several highly regarded HIV guidelines (Clumeck, et al) recommend that HLA-B5701 be tested on all patients initially rather than wait for abacavir use. It is a test needed only once in the lifetime of the patient. Therefore, the testing at issue 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 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 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found Botox injections received on 10/9/14 and 10/29/15 were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, the patient received Botox injections to her pectoralis muscles on two occasions following breast reconstructive surgery. However, there is a lack of support in the peer reviewed medical literature that Botox injections in the pectoralis muscle post expander breast reconstruction are of proven value. Winocour and colleagues performed a literature review to determine the efficacy of Botulinum toxin A (BTX-A) injections for pain relief following placement of subpectoral tissue expanders and breast implants. They concluded that there is a paucity of high-quality published trials assessing the efficacy and safety of BTX-A in relieving post-operative pain associated with sub-pectoral placement of tissue expanders and breast implantsFurther properly conducted and reported randomized trials providing high-level evidence assessing the efficacy and safety of this practice are required. In addition, Lo and Aycock reported on a prospective, randomized, double-blinded controlled trial in 23 patients to evaluate the effects of intraoperative injection of 100 U of botulinum toxin into the pectoralis muscle on one side versus placebo on the contralateral side during immediate tissue expander reconstruction after bilateral mastectomy. The authors found that there was no statistically significant difference between preoperative to postoperative changes in the pain scores on the botulinum toxin side compared to the control side at any time point postoperatively. The authors concluded that Intraoperative injection of the pectoralis muscle with botulinum toxin is not an effective method to improve pain control in tissue expander reconstruction. All told, there is a lack of evidence in the peer-reviewed literature supporting the services at issue as likely to be more beneficial for treatment of the patients 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 treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.