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

Summary Reviewer 

The patient is a 51-year-old female with a long history of obsessive-compulsive disorder, major depressive disorder, generalized anxiety disorder, insomnia related to obsessive-compulsive disorder and tardive dyskinesia that is the result of previous medications used to treat her obsessive-compulsive disorder. Since 2017, treatment for her significantly worsening obsessive-compulsive disorder symptoms have included duloxetine, Lexapro, mirtazapine, paroxetine, propranolol, sertraline and venlafaxine. Antidepressant treatments made her feel worse and increased her anxiety. Gabapentin was not effective. The records noted that Abilify was not effective. Latuda was effective but caused tardive dyskinesia. The records document significant functional decline, including significant anhedonia, inability to get out of bed, and difficulty with sleep. The patient was started on a trial of Nuedexta, and her obsessive-compulsive disorder and depression were significantly ameliorated. She has requested authorization and coverage for Nuedexta 20-10 mg capsules. 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 physician reviewer found that the submitted records support the medical necessity of the requested medication. Kadriu and colleagues noted that, An open label, one-arm trial of 20 patients with treatment resistant depression who received oral doses of Nuedexta (45 mg and 10 mg, respectively) every 12 hours found that, after 10 weeks, 45% of subjects had experienced remission and 35% had experienced response. The paper by Henter and colleagues highlighted the evidence supporting the antidepressant effects of various glutamatergic modulators such as Nuedexta. The records document debilitating obsessive-compulsive disorder and depression, significant anhedonia and loss of ability to function. The patient was at risk for inpatient psychiatric admission for her severe symptoms and depression prior to her trial of Nuedexta. The documentation indicates that the patient has treatment resistant depression in addition to her treatment refractory obsessive-compulsive disorder. The use of Nuedexta led to clinically significant improvement in her function, when previous first-line treatments had failed, and in fact, had caused her anxiety to worsen. Therefore, Nuedexta 20-10 mg capsules are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 46-year-old female enrollee has requested reimbursement for injection of platelet-rich plasma performed on 12/21/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the records document a history of chronic right ankle pain and bilateral heel pain. Surgery was primarily performed due to the enlarging soft tissue mass over her right lateral ankle. She reported symptoms which were characteristic of chronic plantar fasciitis. The medical evidence does not support platelet-rich plasma injections of the ankle and foot in this setting. Moraes and colleagues performed a review of 1,088 patients from 19 clinical trials for multiple conditions. The authors noted that a lack of standardization and varying preparation techniques were areas of concern. The authors concluded that there was insufficient evidence to support platelet-rich therapies for musculoskeletal soft tissue injuries. In this case, the patient was being treated for chronic bilateral plantar fasciitis as well as a right ankle soft tissue mass. Platelet-rich plasma injections were performed to treat chronic bilateral plantar fasciitis which had been refractory to conservative management. The available literature regarding tendinopathies and arthropathies of the foot and ankle do not indicate platelet-rich plasma injections are more beneficial for the treatment of foot and ankle conditions than standard conservative management. In sum, injection of platelet-rich plasma performed on 12/21/18 was not likely to have been of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has obstructive sleep apnea and has a long palate. The nasal obstruction has been relieved since the sleep study was done in 2017, and an updated sleep study has not been performed. The patient has not been able to tolerate the continuous positive airway pressure device, but it is unclear if he has tried the device after the septoplasty. The Inspire device has been approved for the treatment of obstructive sleep apnea. At this point, the patient is not a candidate for the Inspire device given the palate appears to be the larger contributing factor to his sleep apnea compared to the base of tongue. If the patient fails treatment of the palate, and he continues to have sleep apnea and is intolerant of the continuous positive airway pressure, then the patient may become a candidate for the Inspire device at that point. At this time, the superior efficacy of the requested services has not been established. In sum, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that based on the recent trials comparing patent foramen ovale closure to antiplatelet therapy, patent foramen ovale closure is superior to antiplatelet therapy for preventing future ischemic events. However, in each of the trials, the patients selected had evidence of definite ischemic infarcts. This patient had only clinical symptoms. Therefore, it is unknown whether antiplatelet therapy alone may be superior or equal to patent foramen ovale closure in this population. If recurrent symptoms/transient ischemic attack recur on antiplatelet therapy, then patent foramen ovale closure would be appropriate in the absence of any other etiology, such as paroxysmal atrial fibrillation. Thus, patent foramen ovale closure is not likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 43-year-old male enrollee has requested authorization and coverage for Sovaldi 400 mg, Daklinza 60 mg and Ribavirin 600 mg for 24 weeks. The Health Insurer has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollee's hepatitis C virus. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to nonliver-related comorbid conditions. Per the guidelines, patients with cirrhosis are high priority for therapy, and patients with diabetes mellitus are at risk for fast progression of fibrosis. This patient is interferon-ineligible due to anxiety. The guidelines recommend that cirrhotic interferon-ineligible patients with genotype 2 hepatitis C who have failed Sovaldi/Ribavirin regimens should be treated with Sovaldi/Daklinza and Ribavirin for 24 weeks. This is based partially on the results of two clinical trials (Sulkowski et al and Wyles et al). Delay in treatment may result in decreased survival (Jezequel et al).  For these reasons, the requested treatment with Sovaldi 400 mg, Daklinza 60 mg, and Ribavirin 600 mg for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Therefore, I have determined the requested medications are 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 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that the use biologics such as Remicade in ulcerative colitis has been proven. However, when a patient loses response to Remicade, this may entail increasing the dose. In this case, there is concern as the disease is active and the patient is symptomatic. The concern between total loss of response, low antibody level to the biologic, or a completely different diagnosis entails completely different measures varying from change or increase in dose of biologic to alternate treatment. Moreover, it has been shown in the medical literature that checking for such antibodies helps optimize clinical response by helping achieve a more optimal drug concentration. Given this support, the Anser IFX testing performed on 11/11/15 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 42-year-old female who presented to her provider on 3/9/22. The records indicated 
that the patient noted left thyroid swelling in January 2020. The patient has requested authorization 
and coverage for additional thyroid tissue removal surgery. The Health Insurer has denied this 
request and reported that the requested service is 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 supports the medical necessity of the requested service. The 
decision to pursue surgical intervention, either total thyroidectomy or lobectomy, is typically based 
on the results of a preoperative biopsy in the form of a fine-needle aspiration (FNA). In this case, 
the FNA was suggestive of a follicular neoplasm. The dilemma with this diagnosis is that cancer 
can only be definitively established on gross tissue architecture, which has historically necessitated 
excision of at least the lobe of the thyroid containing the suspicious nodule. However, recent 
advances in genetic sequencing have augmented this algorithm. If genetic evaluation of the FNA 
establishes a low ROM, many practitioners forgo removal of the thyroid in favor of observation. 
In this case, as the genetic testing was noted as suspicious, with a ROM of 50%, performing at 
least a lobectomy was appropriate. In many cases of well differentiated thyroid carcinoma, such 
as papillary and follicular, lobectomy alone is sufficient for treatment. However, certain factors 
necessitate returning to the operating room to remove the opposite thyroid lobe in a completion 
thyroidectomy. One of these factors is the size of the cancerous nodule. The American Thyroid 
Association (ATA) guidelines for the management of differentiated thyroid carcinoma notes that 
for nodules greater than four centimeters, total thyroidectomy is recommended when a FNA is 
suggestive of carcinoma, or a completion thyroidectomy when carcinoma is ultimately diagnosed 
on lobectomy, as in this case, due to a higher-than-acceptable risk of recurrence (ROR) when the 
cancerous nodule is greater than four centimeters. In a systematic review investigating risk factors 
for recurrence in follicular thyroid carcinoma, Grnland and colleagues found that the overall rate 
of  recurrence  was  13.6%,  with  64.8%  of  recurrences  representing  distant  metastasis,  and 
specifically identified a size greater than four centimeters as a statistically significant risk factor 
for recurrence. In this clinical setting, given that current medical literature supports completion 
thyroidectomy to mitigate the patients risk of recurrence of follicular thyroid carcinoma most 
effectively, the requested service is medically indicated. Therefore, additional thyroid tissue 
removal surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of an 11-year-old male enrollee has requested reimbursement for the FirstStepDx PLUS test provided on 7/6/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStepDx PLUS test provided on 7/6/16 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 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: Overturned

Summary Reviewer 2

A 61-year-old male enrollee has requested authorization and coverage for Tykerb. 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 salivaray gland tumors are rare. HER2 is expressed in about one-third of salivary gland tumors. Tykerb (lapatinib) is an orally active dual inhibitor of EGFR and HER2. Agulnik and colleagues studied this medication in a phase II trial of 40 patients. Although no responses were observed, 47 percent of patients treated with lapatinib had prolonged tumor stabilization of at least six months. Since disease progression prior to enrollment was required in this trial, the prolonged tumor stabilization may be more likely due to true drug effect. The medical evidence supports the requested medication in this patients case. In sum, Tykerb is likely to be of greater benefit than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for injection, anesthetic agent, greater occipital nerve, provided on 6/05/19 and 6/12/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. The patient has been diagnosed with seizure disorder and Chiari malformation. The records document occipital headaches when supine. The use of occipital nerve blocks is typically indicated for greater occipital neuralgia and currently does not have any indicated for Chiari malformation. The sub-occipital headaches are mostly likely secondary to the Chiari malformation. The records do not support the diagnosis of greater occipital neuralgia. Thus, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were not likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 32-year-old male enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees central nervous system (CNS) germinoma. The physician reviewer found that IMRT is a tool that providers can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms to maximize dose to the target and minimize dose to normal tissues. In the medical literature, Sakanaka and colleagues evaluated IMRT for CNS germinoma. The authors found that IMRT demonstrated better conformality in target coverage and better sparing of normal brain with IMRT in the treatment of CNS germinoma than 3D conformal radiation therapy. For CNS germinoma, the prescribed dose is relatively low and still below the accepted tolerance of the brainstem, optic nerves, retina and below the risk for brain necrosis. However, the target is complex in shape and IMRT would be more conformal in this clinical setting. For these reasons, the requested IMRT for this case is an accepted standard and supported as medically necessary for treatment of this patients CNS germinoma. In sum, the requested services are 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 38-year-old female has requested reimbursement for laboratory testing performed on 7/06/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who had a history of recurrent pregnancy loss. The physician reviewer found the current medical evidence fails to support the services at issue in this setting.  The records indicate that the patient had a second trimester pregnancy loss.  The likely etiology of this loss would be suggestive of a spontaneous or inherited genetic mutation or a complication of implantation/placental development.  Secondary to other early genetic testing results the patient had Non Invasive Prenatal Screen Testing, the results of which were negative.  Given the patient had studies suggestive of a structural anomaly within the uterus and that she subsequently underwent a septum removal, it is possible that was the underlying etiology.  Per the American College of Obstetricians and Gynecologists, 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.  Although there may be an association in these cases, there is insufficient clinical evidence that antepartum prophylaxis with unfractionated heparin or low molecular weight heparin prevents recurrence in these patients.  The only superseding issue would be if the patient had a personal history of venous thromboembolism or a first-degree relative with a history of high-risk thrombophilia.  No such history appears to be presented in this case.  Thus, laboratory testing performed on 7/06/15 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: Overturned

Summary Reviewer 

A 39-year-old female enrollee has requested reimbursement for emergency and post stabilization services and care provided from 5/01/19 through 5/04/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that evidence-based medical literature generally support open reduction and internal fixation of unstable ankle fractures several days to a few weeks after injury. Continued inpatient admission is indicated until acceptable patient status for next level of care is achieved, including pain is absent or adequately managed on oral medications, injuries stabilized as needed (e.g. cast, orthoses), and the patient is ambulatory and can perform activities of daily living or activity at baseline or activity acceptable for next level of care. This patient sustained a left trimalleolar displaced fracture on 5/01/20. She was admitted to inpatient care with severe swelling of the left foot and toes for surgical management. She was provided inpatient care, including ongoing intravenous fluids, lower extremity neurovascular checks, preoperative cardiac evaluation, swelling reduction, deep vein thrombosis prophylaxis, and pain management in the preoperative period. She underwent open reduction and internal fixation of the left ankle fractures on 5/04/19 and was subsequently discharged home. The services provided in the emergency and inpatient setting as outlined above would appropriately be considered acute level of care for treatment of the enrollees acute displaced ankle fracture. Based on the records, emergency and post stabilization services and care provided from 5/01/19 through 5/04/19 were medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement for residential treatment center services from 5/28/16 through 6/10/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. The records available for review noted that the patient was receptive to interventions and actively participated in treatment and programming. The resident complied with her meal plan overall. Per the discharge summary, the patient endorsed the self-harming instances in an attempt to prolong her stay in the treatment center. A comparison of medications from 5/18/16 to discharge indicated that these medications could have been administered at an outpatient setting and did not necessitate residential treatment. All told, there is no indication from the reviewed records to reflect that this patient could not have been transitioned to a lower level of care during the period in dispute. Therefore, for the reasons stated above, the services at issue were not medically necessary for treatment of this patient. The Health Insurers denial should be upheld.