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

Summary Reviewer 1 
 
A 31-year-old female enrollee has requested reimbursement for evaluation of arterial inflow and 
venous  outflow  of  abdomen,  retroperitoneum,  scrotal  contents  and/or  pelvic  organs  and 
detailed  fetal  ultrasound,  fetal  doppler  echocardiography  and  umbilical  artery  doppler 
velocimetry on 3/11/22 and 5/10/22. The Health Insurer has denied this request and reported 
that the services at issue were investigational for the evaluation of the enrollees high risk 
pregnancy.  The  physician  reviewer  found  that  Doppler  ultrasonography  is  a  noninvasive 
technique used to assess the hemodynamic components of vascular resistance in pregnancies 
complicated by fetal growth restriction. There is currently a lack of evidence that umbilical artery 
Doppler velocimetry provides information about fetal well-being in fetuses with normal growth. 
In this case, the records did not demonstrate that the patients pregnancy was complicated by 
fetal growth restriction. Both theoretic models and large clinical studies suggest that initiating 
antepartum fetal testing at 32 weeks of gestation or later is appropriate for most at-risk patients. 
In this case, the dates of service at issue were at 12.5 weeks and at 21.2 weeks of gestation. The 
patient had chronic hypertension that was well-controlled and gestational diabetes. For patients 
with hypertension that is well-controlled on medication, as in this case, standard therapy based 
on American College of Obstetricians and Gynecologists (ACOG) guidelines is weekly testing 
beginning at 32 weeks gestation with nonstress tests and a biophysical profile. For patients with 
gestational diabetes, a single third-trimester ultrasound examination at 36 to 39 weeks to 
estimate fetal weight, regardless of degree of metabolic control or requirement for insulin or oral 
antihyperglycemic medications, is recommended. While a Doppler ultrasound may be indicated 
in the case of intrauterine growth restriction (IUGR), the records did not document that this was 
the case in this patient. Therefore, evaluation of arterial inflow and venous outflow of abdomen, 
retroperitoneum, scrotal contents and/or pelvic organs and detailed fetal ultrasound, fetal 
doppler echocardiography and umbilical artery doppler velocimetry on 3/11/22 and 5/10/22 was 
not likely to have been more beneficial for evaluation of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 34-year-old female enrollee has requested reimbursement for partial hospitalization program level of care provided on 1/08/16, 11/11/16, 1/12/16, 1/15/16, 1/18/16, 1/19/16, 1/20/16, 1/21/16, 1/22/16, 1/25/16, 1/26/16, 1/27/16, 1/28/16, 1/29/16, 2/01/16, 2/02/16, 2/03/16, 2/04/16, 2/05/16, 2/08/16, 2/10/16, 2/11/16, 2/12/16, 2/15/16, 2/16/16, 2/17/16, 2/18/16, 2/19/16 and inpatient outpatient treatment provided on 2/24/16, 2/26/16, 2/29/16, 3/01/16, 3/02/16, 3/03/16, 3/04/16, 3/07/16, 3/08/16, 3/09/16, 3/10/16, 3/11/16, 3/17/16, 3/18/16, 3/21/16, 3/24/16, 3/25/16, 3/28/16, 3/29/16, 3/30/16 and 3/31/16. 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 patients require safe and stable living environments in order to develop their recovery skills. The submitted records support the services at issue in this patients case. The six ASAM dimensions for partial hospitalization program level of care were met. There was a minimal risk of severe withdrawal, although she had to have detoxification prior to the disputed timeframe. She had no medical conditions/complications. Her emotional/behavioral/cognitive conditions/complications included a moderately severe mixed manic-depressive state. The patient was somewhat motivated to change, although she required structure of a day program at least to engage and get her on track. She had a high likelihood of relapse without close monitoring and support, given her relapse during the program. The records documented a minimally supportive environment. Given the severity of the patients illness, partial hospitalization program level of care and stepdown to intensive outpatient program treatment were in accordance with generally accepted standards of medical practice. Therefore, partial hospitalization program level of care provided on 1/08/16, 11/11/16, 1/12/16, 1/15/16, 1/18/16, 1/19/16, 1/20/16, 1/21/16, 1/22/16, 1/25/16, 1/26/16, 1/27/16, 1/28/16, 1/29/16, 2/01/16, 2/02/16, 2/03/16, 2/04/16, 2/05/16, 2/08/16, 2/10/16, 2/11/16, 2/12/16, 2/15/16, 2/16/16, 2/17/16, 2/18/16 and 2/19/16 and intensive outpatient treatment provided on 2/24/16, 2/26/16, 2/29/16, 3/01/16, 3/02/16, 3/03/16, 3/04/16, 3/07/16, 3/08/16, 3/09/16, 3/10/16, 3/11/16, 3/17/16, 3/18/16, 3/21/16, 3/24/16, 3/25/16, 3/28/16, 3/29/16, 3/30/16 and 3/31/16 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
This patient is 63-year-old male who presented to the emergency room on 7/22/22. The patient 
reported a posterior headache associated with dizziness and lightheadedness. The patient has 
requested reimbursement for an emergency room claim for 7/22/22 through 7/23/22. 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 physician reviewer found that the submitted documentation  does  not  support  the medical 
necessity of the services at issue. Cerebellar, or posterior infarcts, are notoriously difficult to 
diagnose without obtaining a brain MRI. In this case, the patient reported dizziness and had 
abnormal heel-to-toe tandem walking. As a hemorrhagic stroke was ruled out, a brain MRI was 
necessary. Given that a brain MRI could have been obtained from the emergency department or at 
a lower level of care, such as observation level of service, the service at issue was not medically 
indicated. Therefore, the emergency room claim for 7/22/22 through 7/23/22 was not medically 
necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 45-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Gamunex-C from 7/01/21 forward. The Health Insurer has denied this request and reported that the medication at issue was and is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that standard treatment of small fiber neuropathy is dependent on the underlying etiology as well as treatment of associated neuropathic pain, which can include several different classes of medications. In small fiber neuropathy, current neuropathic pain treatment options are generally insufficient to relieve the pain substantially. Small fiber polyneuropathy has various underlying causes, including associations with systemic autoimmune conditions. Intravenous immunoglobulin (IVIG) is a first-line treatment for immune-mediated neuropathies such as Guillain-Barre syndrome, chronic inflammatory demyelinating polyneuropathy, and multifocal motor neuropathy.
In a retrospective study by Liu and colleagues, 55 patients with objectively confirmed small fiber polyneuropathy (SFPN) attributed to autoimmunity received IVIG for more than three months. The proportion of autonomic function tests (AFT) interpreted as indicating SFPN dropped from 89% at baseline to 55%. Sweat production normalized, and the other four domains all trended toward improvement. Overall, 74% of patients rated themselves aimproveda, and their neurologists labeled 77% as aIVIG respondersa. The authors concluded that the results provide Class IV evidence suggesting that IVIG is safe and effective for rigorously selected SFPN patients with apparent autoimmune causality.
A review article by Oaklander reviewed various studies regarding immunotherapy for distal SFPN. The authors noted, aThese reports also provide a rationale for treating carefully selected patients with immunomodulatory therapies. Candidates should have symptoms consistent with SFPN, objective confirmation of diagnosis, exclusion of other causes, failure to improve with symptom management, and, ideally, serologic markers of immunity/inflammation.a In this case, the patient has small fiber polyneuropathy and an autoimmune condition. Her clinical symptoms have improved with the use of IVIG. Based on the studies noted above, patients with autoimmune small fiber neuropathy may improve clinically with IVIG. Therefore, Gamunex-C from 7/01/21 forward was and is likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 46-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee's hepatitis C virus. The physician reviewer found the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus genotype 1a. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. Any decision to defer or delay treatment runs the risk of allowing a subset of patients to progress to cirrhosis and thereby increase their future risk of hepatic decompensation or hepatocellular carcinoma. As such, the requested Harvoni is medically necessary for treatment of the patients hepatitis C virus. For the reasons stated above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 42-year-old female enrollee has requested reimbursement for gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) on 4/6/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic breast cancer to the liver and bones. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is no convincing evidence that the assay adds to the decision-making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not convincing.  A recent randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. All told, gene test FoundationOne (procedure codes 81201, 81210, 81211, 81235, 81270, 81275, 81292, 81295, 81298 and 81321) performed on 4/6/16 was not likely to have been more efficacious than other methods of evaluating this patient.  Therefore, for the reasons stated above, the services at issue were not likely to have been 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 40-year-old female enrollee has requested reimbursement for Anser ADA diagnostic testing performed on 2/18/15. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees medical condition. The physician reviewer found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the Anser ADA testing was ordered to determine the etiology for possible loss of response to Humira and to direct the management of the patients Crohns disease. The test revealed a lack of antibodies and that the drug was present. The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility. Moreover, the effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response. However, loss of response can be due to multiple factors, and the appropriate method for determination of the cause for loss of response is not clear. Given the lack of supporting demonstrating definitive utility, the ADA diagnostic testing performed on 2/18/15 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 

The parent of a 13-year-old female enrollee has requested reimbursement for residential mental health treatment provided from 1/31/19 through 3/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 2. The medical records indicate that the patient was not actively suicidal. She did not engage in self-harm behaviors but did have a reported history of passive suicidal ideation. With regards to functional status, the records support a score of 3. The patient has had issues with level of function due to mental illness in the past and relationship problems, but overall showed appropriate daily functioning while in treatment, including intact activities of daily living. In terms of comorbidity, the records support a score of 1. The patient did not have active medical problems or substance use that affected her primary psychiatric issues. With regards to level of stress of the recovery environment, the records support a score of 2. There is no indication of an unsafe home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patients family was actively involved in treatment on a regular basis. With regards to resiliency and treatment history, the records support a score of 3. It appears that the patient did not attempt any forms of the intensive treatment on an outpatient basis. In terms of acceptance and engagement of the patient, the records support a score of 2 to 3. The patient was hesitant to participate in treatment after admission to the residential treatment program. There was no indication that she was not participating in her outpatient treatment prior to the residential treatment center admission. With regards to acceptance and engagement of the parent, the records support a score of 2. The parent worked actively and constructively with clinicians on a regular basis. Thus, the patient has a composite score of 17 to 18. This score correlates intensive outpatient services. Therefore, residential mental health treatment provided from 1/31/19 through 3/04/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 38-year-old male enrollee has requested reimbursement for polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that the use of the gastrointestinal pathogen panel test is not supported in this case. The test is used to diagnose diarrhea, and there are several pathogens that can cause diarrhea. The American Academy of Family Practice guidelines for evaluation of acute diarrhea do not recommend the use of polymerase chain reaction assays at this time. Guidelines for the evaluation of diarrhea do not recommend nucleic acid panels in most cases either, and Riddle and colleagues stated, aIn addition, the significance of an identified organism may not be clear as these molecular technologies, which involve nucleic acid amplification, are limited to our existing knowledge of a microbesa genome and do not discriminate between viable and non-viable organisms. As a result, they can detect microbes at nonpathogenic levels. Given the high rates of asymptomatic carriage of enteropathogens, this can be a considerable problem. To confound matters, further multiplex techniques are more commonly associated with increased detection of mixed infections and the relative importance of each pathogen may be unclear.a Guidelines from the Infectious Diseases Society of America do not recommend the gastrointestinal pathogen panel in cases of diarrhea without severe diarrhea characterized by complications such as fever or hematochezia.  Therefore, polymerase chain reaction testing for gastrointestinal pathogen panel performed on 12/16/19 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement for substance use residential treatment from 5/16/15 through 6/29/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records failed to demonstrate that less restrictive interventions targeting the patients substance use during the episode of illness had either been unsuccessful or would have more than likely been inappropriate.  Upon admission, the patient was engaging and motivated for treatment with a strong desire to succeed.  He reported no history of withdrawal symptoms.  He had no acute psychiatric comorbidity or unresolved medical issues.  Although many of his decisions were self-defeating, he did not pose an imminent threat to self or others.  Prior to admission, the patient was engaged in neither specialty treatment services nor community programming.  He had not pursued trusted treatment interventions for cannabis use disorder that can be safely and effectively delivered in the outpatient setting, such as motivational enhancement therapy, cognitive behavioral therapy, twelve-step facilitation, contingency management or family therapy, which was identified at presentation as an intervention of critical importance in this particular case.  In sum, there was no evidence to suggest that comprehensive specialty services provided at a lower level of care, such as partial hospitalization or intensive outpatient programming either at home or in a sober living environment would have been unreasonable or consistent with inadequate care.  Thus, substance use residential treatment from 5/16/15 through 6/29/15 was not medically indicted 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: Experimental
Decision: Upheld

Summary Reviewer 1


A 20-year-old male enrollee has requested reimbursement for the Anser IFX testing provided on 10/26/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease status post resection. The physician reviewer found that some evidence exists to suggest that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. However, the reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser IFX testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, the Anser IFX testing provided on 10/26/15 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 52-year-old male enrollee has requested reimbursement and prospective authorization and coverage for elotuzumab (Empliciti) from 1/4/17 through 7/3/17. The Health Insurer has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollees myeloma. The physician reviewer found that Empliciti is a humanized monoclonal antibody against SLAMF7, which is expressed on most myeloma cells. Empliciti was approved by the U.S. Food and Drug Administration (FDA) in 2015 for use in patients with relapsed and refractory myeloma in combination with lenalidomide and dexamethasone. This patient received Empliciti as part of a clinical trial. At the time of this patients enrollment, there was already compelling data on the efficacy of Empliciti in patients with myeloma (Lonial; et al; Zonder, et al). Given this support, the requested treatment with Empliciti from 1/4/17 through 7/3/17 was and is 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 medication at issue was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.