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

Summary Reviewer 2
A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines endorse the use of intraoperative radiation therapy in the treatment of breast cancer. The patient meets all of the suitable criteria for the use of intraoperative radiation in patients with DCIS. Furthermore, intraoperative radiation would decrease toxicities from the patient undergoing radiation a second time to an adjacent field. Therefore, the intraoperative radiation therapy performed on 7/19/16 has been established as 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 service at issue was 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: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of an eight-year-old male enrollee has requested authorization and coverage for Exondys 51. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees Duchenne muscular dystrophy. The physician reviewer found that there is sufficient support for the requested medication in this patients case. The U.S. Food and Drug Administration (FDA) had approved this medication in this setting. Mendell and colleagues reported that eteplirsen restored dystrophin in the 30 and 50 mg/kg/week cohorts, and in subsequently treated, placebo-controlled subjects. No severe adverse events were encountered. This crossover study showed that those patients who received placebo and later received Exondys 51 also showed improvement, proving the medication is beneficial. Thus, Exondys 51 is likely to be more effective than other treatment alternatives. Based upon the information set forth above, the requested medication 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 44-year-old female enrollee has requested authorization and coverage for the Intracept procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Khalil and colleagues performed a randomized controlled trial to compare the effectiveness of intraosseous radiofrequency ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain. The authors noted maintenance of clinical improvement at two years following radiofrequency ablation of the basivertebral nerve. This trial included 140 patients with chronic low back pain that had been present for at least six months, with Modic Type 1 or 2 vertebral endplate changes. The patients were divided into two groups; half received the Intracept and the other half received standard care. The results showed clear superiority of radiofrequency ablation of the basivertebral nerves compared to standard care. In this case, the patient has chronic low back pain with Modic Type 1 vertebral endplate changes at L4-5 and L5-S1. The provider has tried other options, with documented failure. The requested Intracept procedure is known to have a high rate of success. Therefore, the requested Intracept procedure is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 43-year-old female enrollee has requested authorization and coverage for immune globulin injection 500 mg (Gamunex-C). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The medical evidence does not support the use of intravenous, intramuscular, or subcutaneous immune globulin as a treatment to prevent recurrent spontaneous abortion in pregnant women. The American College of Obstetricians and Gynecologists does not support the requested services for the treatment of this patient. The use of intravenous immune globulin for pregnancy loss prevention has not been demonstrated by large scale, prospective clinical trials to have superior outcomes compared to existing therapies. Therefore, immune globulin injection (Gamunex-C), 500 mg is not likely to be of greater benefit than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 59-year-old male enrollee has requested reimbursement for positron emission tomography/computed tomography (PET/CT) scan and magnetic resonance imaging (MRI) of the pelvis performed on 6/03/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found this patient had appropriate but incomplete surgical treatment for his prostate cancer.  Per the medical records, C-11 choline PET scan and MRI of the pelvis including a transrectal coil discovered the residual tumor, allowing for appropriate treatment.  There is sufficient support for C-11 choline PET scans to search for biochemical cases of recurrence when conventional imaging has proven to be negative.  Additionally, the use of MRI of the pelvis when prostate recurrence is suspected is commonplace and indicated particularly with endorectal coil in order to visualize the prostatic bed and adjacent lymph nodes.  Also, this exam can be compared with the results of the C-11 choline PET scan.  The combination of the two offers the best detail of the prostatic bed and surrounding lymph nodes, which is crucial in a patient with a history of biochemical prostate cancer recurrence without obvious cause on conventional imaging.  Since conventional imaging has been suboptimal for this patient in the past, the PET/CT scan and MRI of the pelvis performed on 6/03/15 were medically indicated for the evaluation of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 57-year-old male has requested authorization and coverage for cervical artificial disc replacement.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  This patient has symptoms noted since May 2012 which suggest multilevel nerve root changes which would not necessarily be addressed through a C3-4 discectomy and artificial disc replacement.  Complications specific to total disc replacement include implant failure, wear, bone implant failures, iatrogenic deformity, segmental kyphosis, failed kinematics, neurological injury and infection.  It is known that the metal to methyl methacrylate bearing surface will be exposed to the wear mechanisms of abrasion, adhesion, fatigue and third body wear.  A continuing particulate load of these particles will occur.  It is known that there is a universal giant cell reaction and chronic inflammation in response to wear debris.  A justification and rationale for total disc arthroplasty is the prevention of adjacent segment disorder through preservation of motion.  However, it remains controversial whether or not motion at the replaced intervertebral disc will be maintained over time, and there is evidence that there is a gradual loss of motion by reason of a number of factors.  One of the most important of these factors is myositis ossificans, fibrous tissue and bone or an inflammatory response to wear and to the trauma of surgery, which involves the formation of both.  Thus, the requested cervical artificial disc replacement is not likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested services are 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 30-year-old female enrollee has requested reimbursement for emergency department services received on 10/30/17. The Health Insurer has denied this request on the basis that the services were not emergent. The physician reviewer found that review of the submitted documentation reveals the patient complained of a cough that had been present for one week. She denied wheezing, chest pain, fever, or leg swelling. There is no notation made that the patient was feeling short of breath. The patient was described as "in no distress." Her vital signs were normal. Mild wheezing with good air movement was noted. All testing that was performed was normal. The patient received two inhaled beta agonist treatments and oral medication. She declined any intravenous medications. This patient's symptoms were not acute in onset nor were they severe. All told, the patients symptoms on 10/301/7 did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to jeopardize his or her health. Therefore, the Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 50-year-old female enrollee has requested reimbursement for anesthesia services provided on 9/29/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees risk for colon cancer.   The physician reviewer found the patient sites a rationale of malignant hyperthermia as a reason for the monitored anesthesia care used for the colonoscopy and endoscopy. However, the routine sedation for these procedures is not a contraindication for a history of malignant hyperthermia. General anesthesia is not needed for colonoscopy and therefore, this procedure is not at risk of provoking a malignant hyperthermia crisis. The patient is otherwise healthy and does not meet criteria for the use of monitored anesthesia care for colonoscopy or endoscopy. All told, the monitored anesthesia care services provided on 9/29/14 were not medically necessary for evaluation of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2
A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that a commercial gene expression profile test (DecisionDX-Melanoma) has been developed in patients with stage I and II cutaneous melanoma. However, 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 according to published data available. Per the National Comprehensive Cancer Network (NCCN) guidelines, while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas is not recommended. At this time, the gene test performed on 5/13/16 was not likely to be of greater benefit than available standard therapy for the evaluation of 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 3


A 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14.  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 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although Botox is not a first-line therapy for all patients with migraines, there is adequate literature supporting its use for this indication in some patients. The therapy is U.S. Food and Drug Administration (FDA) approved for migraine. In this particular case, the patient failed numerous standard therapies for migraine, including two prophylactic classes of therapies, an anti-seizure medication and an antidepressant medication.  The patient also responded to a course of Botox with a reduction of headaches per month. For this reason, the services at issue were likely to be more beneficial for treatment of the patients chronic migraine than any available standard therapy. Based upon the information set forth above, the services at issue were 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 


A 20-year-old female enrollee has requested reimbursement from 10/25/17 through 11/8/17 and prospective authorization and coverage for residential treatment services. 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 condition. The physician reviewer found that there is support for the medical necessity of the services at issue in this clinical setting. Based on a review of the medical records, the patient was not stabilized and remained symptomatic beyond 10/25/17. On 10/31/17, the patient was documented as having suicidal ideation with a plan to overdose on medications and was placed on close observation. The patient was consistently documented as depressed and anxious, with restricted/flat affect, nightmares, and suicidal ideation. The patient was also documented as frequently taking, as needed, haloperidol, lorazepam, and hydroxyzine for anxiety in addition to her regularly scheduled psychiatric medications.  Documentation from clinical staff on 11/8/17 indicated that the patient was not able to step down to a lower level of care due to the severity of her symptoms and safety concerns.  A study by Vujanovic and colleagues shows that trauma and posttraumatic stress disorder are frequently associated with suicidality and psychiatric readmission rates are high especially amongst patients with physical comorbidities such as in this patients case. This patient has been diagnosed with Ehlers-Danlos syndrome. Additionally, this patient continued to report suicidal ideation and was placed on close observation.  On 11/8/17, she was evaluated by the treatment team and deemed not appropriate for a lower level of care. Therefore, residential treatment services from 10/26/17 through 11/8/17 and future services were and are medically necessary for treatment of this patients medical condition. Therefore, for the reasons stated above, the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2 
 
A 58-year-old male enrollee has requested authorization and coverage for proton beam radiation 
therapy (PBT). The Health Insurer has denied this request and reported that the requested service is 
investigational for the treatment of the enrollees locally advanced esophagus cancer. The physician 
reviewer found that PBT is not likely to be more beneficial for treatment of the patients condition than 
any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/15/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found this patient is a 48-year-old female who has requested reimbursement for bilateral diagnostic mammogram with tomosynthesis on 9/15/15 for a 6-month calcification follow up. The report shows calcifications were unchanged from previous studies, suggesting it is probably benign, BIRADS 3. A 2013 study by Skanne and colleagues found the use of mammography plus tomosynthesis in a screening environment resulted in significantly higher cancer detection rate and enabled radiologists to detect more invasive cancers. Recent studies also show that integrated 2D and 3D mammography reduced false positive recalls (Ciatto, et al). The current literature is sufficient to support the use of breast tomosynthesis over conventional mammogram based upon improved cancer detection rates.  In this patient, the use of tomosynthesis was likely to be more beneficial for the evaluation of her medical condition than standard imaging modalities. For the reasons stated 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 

The parent of a four-year-old female enrollee has requested authorization and coverage for genetic testing. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that Ataxia is an uncommon finding in children with a large number of causes. Genetic etiology can often be identified, particularly in those with early age of onset, family history of ataxia, or consanguineous parents. In this childs case, the very early age of onset indicated a high probability of an underlying genetic cause. Studies of whole exome sequencing (WES), which is more comprehensive than the panel requested here, have shown rates of identification of underlying genetic etiology ranging from 21% to 69%, depending on age and family history of those included. The rate of positive WES in 21% of adults with ataxia suggests a significant likelihood of finding a diagnosis for this child, either by panel test or by WES. Many authors currently recommend WES either as a follow-up test to non-diagnostic ataxia panel genetic testing, or as an initial molecular test due to its comprehensiveness. Specific treatments do exist for some hereditary ataxias, and more clinical trials and therapies are anticipated, increasing the benefits of confirming a molecular diagnosis. The current medical evidence supports genetic testing in this clinical setting. Therefore, the requested genetic testing is medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 35-year-old female enrollee has requested reimbursement for (CPT code 86343) leukocyte histamine release test (LHR) dated on 10/20/15. The Health Insurer has denied this request indicating that the requested procedure are considered investigational for treatment of the enrollees chronic idiopathic urticaria The physician reviewer found the clinical utility of LHR is not well established and there are currently no national Allergy and Immunology or Dermatology guidelines recommending routine use of this test. LHR is a test that consists of basophil histamine release assay.  This assay is used to detect anti-Fc-epsilon-RI-alpha antibodies. Some concerns with LHR is that there is evidence against a pathogenic role of autoantibodies to IgE or Fc-epsilon-RI and they are not specific to CU.  Anti-Fc-epsilon-RI-alpha antibodies have been identified in healthy normal people and those with other autoimmune diseases.  The level of these antibodies do not appear to change with the clinical disease activity. The presence of these antibodies do not appear to predict refractory disease. In this patients case, her symptoms are consistent with chronic idiopathic urticaria. Her evaluation to include LHR have all been negative.  As such, (CPT code 86343) leukocyte histamine release test (LHR) that was rendered on 10/20/15 was not likely to have been more effective than current standard therapy for evaluation of this patient. Therefore, for the reasons stated 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  
The patient is a 45-year-old female with a history of severe Raynauds disease with ulceration. 
The patient reported being diagnosed with the condition for the past four to five years with 
worsening symptoms. The provider recommended Botox injections of 100 units for a quantity of 
2 per 30 days for the treatment of the patients Reynards disease symptoms. The Health Insurer 
has denied the requested medication as not medically necessary. This denial is the subject of this 
appeal and determination. The physician reviewer found that the treatment of severe and refractory 
Raynauds disease must be individualized based on clinical findings, presentation, and other 
studies. The medical literature contains mainly case reports and small studies supporting the use 
of Botox for severe and ulcerating Raynauds disease in patients with atypical presentation and in 
such an advanced stage. A randomized controlled trial by Motegi and colleagues supported the 
efficacy of Botox for the treatment of Raynauds disease and indicated a decrease in ulcerations. 
Further, recent medical literature supports the use of Botox for Raynauds syndrome for systemic 
sclerosis (Jerjen, et al.). In this case, the patient has documented findings consistent with severe 
Raynauds disease including ulceration of the digits. The record reflects that the patient reported 
increased vasospasm with associated pain and nail dystrophy having a significant impact on her 
quality of life. The patient is currently on nifedipine 30 mg, but per a clinic note dated 3/15/23, the 
effect of the medication has waned. The record reflects that the patient has experienced a good 
response to Botox on her hands and feet. The refractory nature of the patients disease and the 
presence of ulcerations suggests potential loss of function if the disease continues, thus Botox is 
indicated for the treatment of the patient. Therefore, the requested Botox injections of 100 units 
for a quantity of two per 30 days are medically necessary for the treatment of the patient.