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

Summary Reviewer 2

A 49-year-old female enrollee has requested reimbursement for endometrial ablation performed on 9/23/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. The records note a history of heavy menstrual bleeding. This patient has opted for a minimally invasive option to control her bleeding. She has opted for an endometrial ablation. Minimally invasive treatment for heavy bleeding is encouraged in order to avoid more invasive treatment, such as hysterectomy. The current medical evidence supports an endometrial ablation in this clinical setting. The services at issue were likely to benefit the patient, with improved quality of life with decreased menstrual bleeding. Therefore, endometrial ablation performed on 9/23/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 38-year-old male enrollee has requested reimbursement for physical therapy provided from 2/16/15 through 3/16/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees status post right knee arthroscopy and right hip arthroplasty. The physician reviewer found the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the services at issue. According to the documentation submitted for review, the patient had already received extensive therapy prior to surgery with similar therapeutic content. His surgery was uncomplicated. Additionally, at least partial concurrent care would be expected after both surgeries. He had reached a plateau with the treatments already provided and an independent home exercise program could have met his needs without ongoing skilled physical therapy oversight. An independent exercise program could have been performed as often as needed rather than during scheduled therapy visits. All told, the physical therapy provided from 2/16/15 through 3/16/15 was not medically necessary in this clinical setting. For the reasons provided, 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 21-year-old female enrollee has requested authorization and coverage for inpatient upper jaw surgery. The Health Insurer has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees midface retrusion and class III malocclusion.  The physician reviewer found that according to the documentation submitted for review, the patient has evidence of class III malocclusion, maxillary retrusion and hyponasal speech. Cleft palate patients with maxillary retrusion have significant sleep apnea from malposition of the maxilla. This produces obstruction in the nasal airway, the nasopharynx, and velum. This demonstrated with hyponasal speech such as the patient in this case. Orthognathic surgery for this patient is medically necessary for correction of the nasal airway obstruction and sleep apnea that results from maxillary retrusion. Moreover, LeFort 1 surgery will move the maxilla forward and give the patient improved speech, improved nasal breathing and relief from sleep apnea and secondary consequences of sleep apnea. Based on the medical documentation provided for review, the request for inpatient upper jaw surgery has been established as medically necessary for treatment of the patients medical condition.  Therefore, the requested surgery is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 52-year-old male who has a history of chronic low back pain. The patient has requested authorization and coverage for an MRI. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of this patient. The physician reviewer found that when to obtain specialized cross-sectional imaging of the spine is a difficult decision. Pain is a very common complaint, and not everyone who has pain needs a computed tomography (CT) or MRI scan. As a fundamental principle, an imaging study should affect the management of the patient. In this patientas case, although his pain may be significant, a more conservative management would be optimal at this point, at least until it is proven that a conservative approach is unsuccessful, and surgery or interventions should be deferred until absolutely necessary. At this point, it is unclear whether plain x-rays are warranted. This is not to say that plain x-rays might not provide some information, but the possible finding of degenerative change on plain x-rays would also not change the immediate management. As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality is exceedingly common in asymptomatic individuals. It is well known that some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. The American College of Radiology (ACR) has established aAppropriateness Criteriaa to help referring physicians obtain efficient use of imaging modalities to evaluate various clinical presentations. The ACR has established these criteria for chronic neck and low back pain. MRI is felt to be anot usually appropriatea in the management of chronic pain without other red flags. On physical examination, other than the pain, there is no submitted information regarding loss of strength or loss of reflexes or other symptoms, such as incontinence. There is no evidence of prior tumor or infection. While it is always possible that random testing of any organ will demonstrate a significant finding, the likelihood is slim. Based on the submitted records, a lumbar spine MRI is not medically indicated. Therefore, the requested MRI is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 64-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 2/1/16.  The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patients 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 enables the possibility of demonstrating an otherwise occult tumor. Therefore, the breast tomosynthesis performed on 2/1/16 were 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 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: Overturned

Summary Reviewer 1

A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that most experts recommend testing for the five major inherited hypercoagulable risk factors including protein S, C, and antithrombin deficiencies, factor V Leiden and prothrombin gene mutation as well as for anti-phospholipid syndrome in patients less than age 45. However, testing for homocysteine levels and mutational analysis for the responsible gene, methylene tetrahydrofolate reductase (MTHFR), is not routinely recommended. Although elevated levels of homocysteine can be found in patients with thrombosis, the causal role of hyperhomocysteinemia in thrombosis remains unclear. In addition, lowering homocysteine levels with folic acid, pyridoxine, and vitamin B12 does not appear to reduce the rate of VTE in patients with hyperhomocysteinemia. Thus, Factor V Leiden is supported as beneficial, while homocysteine testing is not likely to be more beneficial. Accordingly, the Factor V Leiden genetic testing provided on 3/23/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the homocysteine testing performed on 3/23/16 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, a portion of 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 partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 54-year-old male enrollee has requested authorization and coverage for Gilotrif (afatinib dimaleate tablet 40 mg).  The Health Insurer indicates that the requested medication is investigational for the treatment of the enrollees medical condition. Therefore, the Health Insurer has denied coverage for the requested medication.
At issue is whether the requested medication is likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the current medical evidenced supports the requested medication in this clinical setting. This patient was found to have an EGFR mutation after initial therapy with progression. Therapy at this juncture could be considered first-line therapy for the now known EGFR mutation. Afatinib has been approved by the U.S. Food and Drug Administration as first-line therapy for EGFR positive disease. Therefore, Gilotrif (afatinib dimaleate tablet 40 mg) is likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 45-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 2/6/15. 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 patient is a 45-year-old female who underwent routine screening mammogram with computer-aided detection and digital breast tomosynthesis on 2/6/15.  The mammogram revealed dense breasts, but was negative and unchanged compared with prior exams. The patient is requesting reimbursement for the breast tomosynthesis performed on 2/6/15. The Health Insurer has denied this request as investigational.There is a lack of peer-reviewed literature that supports the use of three-dimensional (3D) breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Thus, the breast tomosynthesis performed on 2/6/15 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 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 1

A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the services at issue in this patientas case. Beckmann and colleagues concluded that their results asupport the clinical application of arthroscopic arthroplasty as a procedure that enhances cartilage repair as an alternative to far more complex procedures that have gained popularity. Furthermore, the data presented supports clinical investigations that recommend not to use suction drainage as by this procedure a considerable amount of the regeneratory potential of postoperative joint effusions might be extracted.a Lubowitz concluded, aArthroscopic abrasion arthroplasty results in a positive outcome in 66% of patients, and may still merit consideration as a salvage procedure.a This patient presented with a history of right medial meniscus tear and a significant loose body in the lateral gutter, resulting in mechanical locking. She had arthritic changes in the knee for which an arthroplasty might be indicated. However, her primary concern was mechanical locking. Surgery was performed on 8/16/19 to include right knee arthroscopy with partial medial meniscectomy, removal of a large intra-articular body, and abrasion chondroplasty for to the undersurface of the patella for grade III and IV chondral wear. Current evidence-based medical literature supports the inclusion of abrasion chondroplasty (CPT code 29879) during concurrent medial meniscectomy and loose body removal for mechanical locking and to potentially delay total knee replacement given her relatively young age and documented grade III to IV chondral wear. Therefore, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The parent of a one-year-old male enrollee has requested reimbursement for inpatient services (neonatal care level 3) provided on 8/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollee, who had a history of tachypnea. The physician reviewer found that while the patient was not feeding well, with intermittent tachypnea, he was overall hemodynamically stable with no need for assisted ventilation. He was on room air, had improving feeding, and was afebrile. His laboratory tests were concerning, but ultimately cultures were negative. He was intermittently tachypneic, but his chest x-ray was consistent with transient tachypnea of the newborn, and he was slowly improving. It was reasonable and appropriate to pursue evaluation for infection in this case. It was also reasonable to monitor the patient at a level of care higher than the newborn nursery. However, he was not critically ill. He could have been safely and appropriately managed at a lower level of care such as Special Care Nursery, level II. Thus, inpatient services (neonatal care level 3) provided on 8/19/17 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: Experimental
Decision: Overturned

Summary Reviewer 1


A 57-year-old male enrollee has requested reimbursement for electromagnetic navigational bronchoscopy performed on 9/29/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees lung nodule.The physician reviewer found there is a lack of support for the services at issue in this patients case.  The medical evidence does not demonstrate that the use of the electromagnetic navigational system improves long-term health outcomes.  The services at issue were not standard of care. There are numerous ways of work-up of potential malignant lung disease, including needle biopsy under fluoroscopy, mediastinoscopy, washing, brushing, and positron emission tomography (PET) scan and/or CT scan follow-up.  Therefore, electromagnetic navigational bronchoscopy performed on 9/29/15 was not likely to have been more effective 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: Overturned

Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for magnetic resonance imaging of the pelvis performed on 3/1/17. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollee who has a history of hemorrhoidectomy and elevated prostate specific antigen (PSA). The physician reviewer found that the medical literature supports the medical necessity of the service at issue in this clinical setting. In this patient, the PSA levels are borderline, and more importance is being paid to the trend in values over the last several tests.  The question is whether to proceed with a biopsy, and the provider is asking for an MRI to assist in that decision. MRI has become a common imaging procedure to better evaluate the prostate. A well-known prostate researcher, Siddiqui has written, targeted MRI/ultrasound fusion biopsy, compared with standard extended-sextant ultrasound-guided biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer, (Siddiqui, p. 390). Current National Comprehensive Cancer Network (NCCN) guidelines state that MRI is not recommended routinely prior to initial prostate biopsy, but emerging data suggest that, in men undergoing initial biopsy, targeting using MRI/ultrasound fusion may increase the detection of clinically significant, higher-risk (Gleason grade > or equal to 4 + 3=7) disease while lowering the detection of lower-risk (Gleason sum 6 or lower-volume Gleason 3 + 4=7) disease. Consequently, for this patient, if the patient does not have suspicious findings on multiparametric MRI, there is only a 3% chance of detecting a clinically significant cancer, whereas if the MRI has suspicious findings, then a biopsy could be warranted. Based on the medical research, multiparametric MRI was useful for this patient, and may have helped him avoid life-altering complications that could occur with unnecessary surgery. MRI of the pelvis performed on 3/1/17 was medically necessary for the evaluation of this patients medical condition. Therefore, for the reasons stated above, the service at issue was medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 49-year-old female. The patient has requested reimbursement for physiotherapy 
services from 11/22/21 through 8/5/22. The Health Insurer has denied this request and reported 
that the services at issue were not medically necessary for the treatment of this patient. The 
physician reviewer found that the submitted documentation supports the medical necessity of a 
portion of the services at issue. The treatment of chronic pain has been extensively studied and 
reviewed  in  medical  literature  over  the  past  few  decades.  Emphasis  has  been  placed  on 
minimizing disability, avoiding opiate use in most cases, and using complimentary medicine when 
a benefit can be shown. Physical therapy is expected to emphasize goal focused disability 
reduction through education and exercise aided by modalities such as heat, ultrasound, or aqua 
therapies. Chiropractic spinal manipulation in relation to chronic pain focuses on symptom 
reduction and well-being. Goertz and colleagues report that chiropractic care, when added to 
usual medical care, resulted in moderate short-term improvements in low back pain intensity 
and disability. Qassem and colleagues note that American College of Physician (ACP) guidelines 
regarding noninvasive treatments for acute, subacute, and chronic low back pain support trials 
of complementary medicine across the domains of acupuncture, chiropractic, or exercise for 
musculoskeletal pain. While the progression from acupuncture to physical therapy to chiropractic 
was appropriate, the records did not document benefits, save for headache reduction in physical 
therapy, in almost 18 months of treatment. In this clinical setting, given that the patient has tried 
and failed other modalities of therapy including physical therapy, acupuncture, and medication 
management, current medical literature supports six chiropractic sessions at a minimum prior to 
seeing benefit. Therefore, six sessions of physiotherapy services from 11/22/21 through 8/5/22 
were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 64-year-old female enrollee has requested reimbursement for residential mental health services provided from 4/6/15 through 5/5/15. 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 residential mental health services provided from 4/6/15 through 5/5/15 were not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not support the initial residential placement. The patient felt isolated and limited in her pursuit of quality of life activities in caring for her husband. However, she did have a supportive brother and was motivated for treatment. Although formidable in its persistence and intensity, there was no mention of a change in the symptom complex. The patient was seeing a psychiatrist in the community, but the extent of non-pharmacologic interventions, including respite care, was not reported. Further, the patient was not seeing a psychologist or therapist at the time of admission. Finally, the patient had not failed a less restrictive treatment setting, such as partial hospitalization or an intensive outpatient program, during this episode of illness. This is significant in this case for two reasons: first, current psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. Thus, the residential mental health services at issue were not medically necessary for treatment of the patients behavioral health condition. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.