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

Summary Reviewer 

The patient is a 38-year-old male with a history of low back and radicular leg pain associated with clinical and imaging evidence of a lumbar disc herniation. The patient has requested authorization and coverage for laminotomy surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that the patient has a history of lumbar disc herniation associated with radiculopathy and leg pain greater than back pain. There is documentation of conservative treatment, including four weeks of physical therapy, in addition to chiropractic care and medications. Although many patients  improve with nonsurgical management, Lorio and colleagues noted, aResults from randomized controlled trials have shown that 35% to 54% of patients assigned to continued nonsurgical care undergo discectomy within six months due to persistent or aggravating symptoms.a Other randomized controlled trials show that discectomy provides faster and/or greater pain relief, and functional recovery as well as patient satisfaction compared to continued nonsurgical care. A review of the recent medical literature indicates that this patient is a good candidate for the requested surgical procedure. Therefore, the requested laminotomy surgery is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 79-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant. 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 in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The Watchman device has been demonstrated in one trial to be non-inferior compared with warfarin and has also showed favorable preliminary results in another trial.  However, device placement in these trials had a high rate of significant complications due to pericardial effusion and procedural stroke related to thromboembolism or air embolization. The Watchman device should still be considered investigational, especially in the subset of patients who are tolerating anticoagulation without bleeding side effects or evidence of recurrent strokes. This patient is tolerating Eliquis and has no documented bleeding episodes. Therefore, percutaneous transcatheter closure of the left atrial appendage with endocardial implant is not likely to be more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 54-year-old female enrollee has requested reimbursement for emergency services provided on 1/26/16. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented for removal of scalp sutures due to a laceration nine days prior to her visit. She admitted to a lingering hangover feeling, but had no specific complaints of headache, vomiting, dizziness, blurry vision, or other symptoms of acute head injury. She denied any symptoms of wound infection. Moreover, the patient was not experiencing the sudden onset of acute symptoms. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on 1/26/16 did not meet prudent layperson criteria for emergency care.
Appeal type: Medical Necessity
Decision: Overturned

Summary  
The patient is a 45-year-old female with a history of atopic dermatitis. The patient states that she 
stopped treatment with Dupixent after experiencing a disruption in treatment from September to 
November 2022. The patient has requested continued treatment with Dupixent. The Health Insurer 
has denied the requested treatment as not medically necessary for the treatment of the patients 
medical condition. This denial is the subject of this appeal and determination. The physician 
reviewer found that the U.S. Food and Drug Administration (FDA) has approved Dupixent for the 
treatment of patients with moderate-to-severe atopic dermatitis whose disease is not adequately 
controlled with topical therapies. A recent consensus article on atopic dermatitis by Boguniewicz 
and colleagues defined moderate-to-severe atopic dermatitis as more than 10% BSA involvement 
and/or involvement of highly visible areas or those important for function and significantly 
impaired quality of life. On review of the current medical literature, Dupixent has the highest-
quality clinical trial evidence for safety and efficacy in atopic dermatitis (Siegels, et al.). The 
records provided for review document that the patient has severe atopic dermatitis and atopic 
neurodermatitis, with 20% BSA involvement. The provider noted that the patient has tried and 
failed treatment with topical steroids, antibiotics, and tacrolimus. The patient has previously 
undergone treatment with Dupixent with significant relief of symptoms. Given these findings, the 
requested Dupixent 300 mg/2 mL, four pens per 28 days is medically necessary for the treatment 
of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 60-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/22/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.   The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as extremely dense. It is specifically patients with dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor. The sonogram is also of value, as sonography will help visualize the cystic lesions. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 9/22/16 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 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: Experimental
Decision: Upheld

Summary Reviewer 1
The parent of a three-year-old female enrollee has requested authorization and coverage for homocysteine, Factor V Leiden, and methylene tetrahydrofolate reductase (MTHFR), testing performed on 6/4/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee whose parent was diagnosed with idiopathic venous embolism and was positive for the MTHFR mutation and Factor V Leiden deficiency. The physician reviewer found that the documentation provided does not support the efficacy of the services at issue in this clinical setting. The medical literature suggests those who have idiopathic thromboembolism before the age of 45 years or at an unusual site may request homocysteine testing. While this may be the case for the patients mother, it is not the case for the patient herself. The American College of Medical Genetics and Genomics (ACMG) has prepared guidelines for FVL testing. This patient may have relatives diagnosed with FVL, but the patients mother is not diagnosed with this medical condition. This would indicate that this patient is not at risk for inheriting FVL from her. While the patient could inherit FVL from her father, there is no report of clotting disorder or FVL in the paternal family history. Moreover, this patient has not had a blood clot. With regards to MTHFR, ACMG recommends against testing for MTHFR polymorphisms in any patient, including in those with relatives with known MTHFR polymorphisms. The literature suggests that there is no risk associated with the A1298C polymorphism in the heterozygous or homozygous state. Further, it could have been predicted that this patient would have at least one copy of A1298C as her mother is homozygous. ACMG guideline suggests testing of homocysteine could be reasonable only in those with two copies of the C677T polymorphisms. In this clinical setting, this is not possible for this patient based on his mother's testing. In sum, homocysteine, FVL, and MTHFR tests performed on 6/4/16 were not likely to have been more beneficial than standard options for the 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: Upheld

Summary Reviewer  
 
The patient is a 27-year-old male who presented to his provider on 4/20/21. The patient has 
requested reimbursement for rhinoplasty (CPT 30420) performed on 5/05/21. The physician 
reviewer  found  that  Friedman  and  colleagues  stated,  Understanding  nasal  anatomy  and 
physiology  are  the  most  important  points  for  successful  functional  rhinoplasty.  Anatomic 
structures playing major roles in nasal breathing functions include the septum, and internal and 
external nasal valves, so physical examination of these regions is essential. Planning for functional 
rhinoplasty involves the identification of the sites of nasal airway obstruction or old trauma and 
addressing those regions during the operation with a number of different techniques that have 
been described. The submitted documentation fails to demonstrate the medical necessity of 
rhinoplasty (CPT 30420). Findings at surgery described a left laterally displaced nasal bone and 
callus over the left nasal dorsum. A laterally displaced bone would be expected to widen the nasal 
airway and not intrinsically cause nasal airway obstruction. A callus is a bump on the outside of 
the nasal bone that would be cosmetically visible but would not be expected to affect the airway. 
There is no report of external bony nasal deviation causing breathing obstruction. There is no 
photographic documentation of bony nasal deviation. Based on the medical information received 
for review, rhinoplasty (CPT 30420) was not medically necessary for treatment of the patients 
medical condition. The California Reconstructive Surgery Statute requires health insurers to cover 
reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures 
of the body caused by congenital defects, developmental abnormalities, trauma, infection, 
tumors, or disease to do either of the following: (1) To improve function. (2) To create a normal 
appearance, to the extent possible. There is no report or documentation that the appearance of 
the nose was not within the wide range of normal. The services at issue were not documented 
to  improve  function,  and  the  California  Reconstructive  Surgery  Statute  is  not  applicable. 
Therefore, rhinoplasty (CPT 30420) performed on 5/05/21 was not reconstructive in nature.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  The medical evidence has not demonstrated the superior efficacy of the device at issue in this patients case. There is a lack of support for an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in this clinical setting. Implantable cardioverter defibrillator placement can be undertaken 90 days after a percutaneous coronary intervention/stenting procedure if the ejection fraction remains below 35 percent or 40 days after a myocardial infarction if there is no intervention and the ejection fraction remains below 35 percent.  There is lack of support for the device at issue in this case. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment modalities. Based upon the information set forth above, the device at issue was 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 65-year-old male enrollee has requested authorization and coverage for Rytary. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees Parkinsons disease. The physician reviewer found that the submitted documentation fails to support the medical necessity for the requested medication. While Rytary is a medication that is commonly used for the treatment of patients with Parkinsons disease, it is prescribed after the patient has tried and failed extended release formulations. The documentation provided do not demonstrate that this has been administered in this patient.  The patient has not been placed on extended release formulations of carbidopa/levodopa. As such, it would be appropriate for the patient to try the extended release formulations prior to being started on Rytary. Accordingly, Rytary is not currently medically necessary for treatment of this patient.  Therefore, for the reasons stated above, the requested medication is 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 39-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 9/6/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees breast examination. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 9/6/16 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 diagnostic procedure 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 1


A 22-year-old female enrollee has requested authorization and coverage for spine nerve treatment, procedure codes 64634 and 64633. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has failed to progress with conservative therapy, injections and physical therapy. Prior treatment with thoracic radiofrequency rhizotomy provided the patient with nine months of pain relief, improved function and the ability to pursue full-time studies as a nursing student.  The available literature indicates that in well-selected patients that respond to thoracic blocks and subsequently radiofrequency treatment, that 6-8 months of analgesia is a positive and favorable response that indicates repeat procedure is indicated. Therefore, spine nerve treatment, procedure codes 64634 and 64633 have 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 requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 30-year-old female enrollee has requested reimbursement for the intensive outpatient program (IOP) treatment provided from 5/26/16 through 6/2/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees bulimia nervosa and alcohol abuse. The physician reviewer found that the records provided for review support the medical necessity of IOP services from 5/26/16 through 5/27/16. On 5/25/16, the patient was continuing to have thoughts of bingeing and purging. She was also struggling with body dysmorphia in the context of rigid and perfectionistic cognitive schemas which fueled anxiety and guilt-based self-criticality. The patient was absent on 5/24/16 and 5/26/16, but based on the longitudinal illness burden and her clinical status on 5/23/16, it was reasonable to have the patient come in to the program on 5/27/16. On that date, the patient continued to have a reluctance to increasing her dietary choices, and expressed guilt for certain meal selections. However, she was willing to increase her food variety, gain weight and address her food fears. By that date, she was tolerating her meal plan, her weight and appearance were healthy, and there was no mention of alcohol use. She was stable on her medications while her most recent mental status examination was unremarkable and included a euthymic mood with linear thought processing. Considering the patients improvement and motivation coupled with a three-month course of specialty care in supervised settings, transition to the outpatient level of care after completing services on 5/27/16 would have been safe, appropriate and consistent with good medical practice. Thus, the services in dispute were medically necessary from 5/26/16 through 5/27/16, but not thereafter. Based on the foregoing discussion, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. 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 prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. An additional methodology in looking at the prognosis is a molecular assay, DecisionDx-Melanoma testing. This looks at the molecular and genetic aspects of an individualas melanoma cells, and then classifies that melanoma based on the five-year risk of metastasis. It is not clear how the five year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it has not been shown that one can use DecisionDx-Melanoma classification to make clinical decisions. In this case, the fact that the melanoma is greater than 1.0 mm, places it in a category for which sentinel node biopsy is recommended. DecisionDx-Melanoma testing does not add to this decision making. Therefore, DecisionDx-Melanoma testing performed on 5/26/20 was not likely to have been more beneficial than any available standard therapy.