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

Summary Reviewer 3


A 66-year-old male enrollee has requested reimbursement for LINX procedure/device performed on 7/27/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has history of belching and heartburn. The physician reviewer found that there is sufficient support for the efficacy of the services at issue in this clinical setting. LINX is a minimally invasive anti-reflux procedure that has been approved by the U. S. Food and Drug Administration. The medical literature has shown that the LINX device has less side effects and may have the potential to be completely reversible. This patient has a diagnosis of persistent chronic GERD that has been partly responsive to PPI dosing and behavioral/dietary modification. The patients GERD appeared controlled and the patient was weaned off PPI. Therefore, in the absence of clear data to establish a standard for treatment of GERD, the LINX procedure/device performed on 7/27/16 was likely to be more effective than the other forms of therapy for treatment of this patients medical condition. 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 63-year-old male enrollee has requested authorization and coverage for surgical insertion of an interspinous process spacer. 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 presents with a 20-year history of chronic low back pain. Signs/symptoms are consistent with lumbar spinal stenosis with neurogenic claudication. Clinical examination findings did not evidence a focal neurologic deficit. There is imaging evidence presented from 2016 that showed no significant central canal stenosis and mild bilateral neural foraminal stenosis at L4/5. There is severe degenerative disc disease noted at the L5/S1 level. There is radiographic evidence from 2016 that documented a mild levoscoliosis with apex at L3/4 and anterolisthesis at L4/5 that reduced 2 mm in extension. He has reportedly failed conservative treatment, including activity modification, medications, and lumbar epidural steroid injections. Current evidence-based medical guidelines and peer-reviewed literature do not fully support the spinal decompression device procedure over the gold standard of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this patients medical condition. Additionally, U.S. Food and Drug Administration (FDA) criteria have not been fully met. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients for whom operative treatment is indicated at no more than two levels from L1 to L5 for a diagnosis of moderate degenerative lumbar spinal stenosis. There is no imaging evidence of moderate spinal stenosis at the L4/5 level on the submitted magnetic resonance imaging (MRI) report. This patients body mass index is documented as 41.28, which is an FDA contraindication. There is no recent documentation of scoliosis films evidencing a Cobb angle of less than 10 degrees, or flexion/extension films showing no progression of the dynamic grade 1 spondylolisthesis noted previously at the L4/5 level, both of which are FDA contraindications. Therefore, the requested surgical insertion of an interspinous process spacer is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

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 there are no medications or procedures that have U.S. Food and Drug Administration (FDA) approval for the treatment of occipital headache. Likewise, there are no medications approved for treatment of Chiari malformation related headache. Positional headache as described can represent cervicogenic headache. Standard treatment for this includes diagnostic and therapeutic anesthetic blocks. This patient has been treated with medications that can help neuropathic pain, without benefit. Per the literature, conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency and occipital nerve stimulation, represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. There is considerable evidence that anesthetic blocks and steroids can be beneficial for neuralgia, migraine, and cervicogenic headache. There is sufficient support for the services at issue in this clinical setting. Therefore, injection, anesthetic agent, greater occipital nerve provided on 6/05/19 and 6/12/19 were likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for intensive outpatient program services provided from 4/25/19 through 7/09/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 1 due to no recent suicidal ideation and impulsive behaviors. With regards to functional status, the records support a score of 3 due to problems in interpersonal interaction and missing treatment. In terms of medical, addictive and psychiatric comorbidity, the records support a score of 3 due to overall medical stability with evidence of substance use. With regards to level of stress of the recovery environment, the records support a score of 3 due to a non-sober living environment. In terms of level of support of the recovery environment, the records support a score of 3 due to few supportive resources. With regards to treatment and recovery history, the records support a score of 3 due to some treatment response in the intensive outpatient program treatment but consideration of worsening symptoms. In terms of engagement and recovery status, the records support a score of 3 due to fair cooperation in treatment but limited ability to accept responsibility for recovery. Therefore, the patient has a composite score of 19. This score correlates with high intensity community-based services. This level of care is consistent with intensive outpatient program level of care. Therefore, intensive outpatient program services provided from 4/25/19 through 7/09/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3A 52-year-old female enrollee has requested authorization and coverage for gene test (gene expression profiling) performed on 9/20/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has been diagnosed with cutaneous melanoma. The physician reviewer found that DecisionDX melanoma is a commercial gene expression profile test, which has been developed in patients with local (stage I and II) or locoregional (stage III) cutaneous melanoma. The most recent assessment was to determine the impact on clinical practice and therefore did not or was not able to discuss the impact on patient outcome. Version 1.2017 of  the National Comprehensive Cancer Network guidelines indicate that for stage II melanoma, that wide excision be pursued with sentinel lymph node evaluation if the tumor is greater than 0.75mm thick. For stage IA, after resection observation is recommended whereas for stage IIB or IIC, interferon alpha should also be considered. There are no current recommendations to undergo genomic or proteomic analysis to assess risk or assess benefit of adjuvant therapy. According to the current guidelines, this data is not definitive. It is unclear if the addition of DecisionDX melanoma to this patients treatment options would have improved her overall care plan since the role in clinical care is still under investigation. As such, the gene test (gene expression profiling) performed on 9/20/16 was not likely to have been superior to 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: Experimental
Decision: Overturned

Summary Reviewer 2

A 59-year-old female enrollee has requested authorization and coverage for heart surgery to correct the heart valve using a catheter (transcatheter valve repair). 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 records noted 2-3+ moderate to moderate to severe aortic regurgitation with normal left ventricular size, normal wall thickness and normal ejection fraction on echocardiography dated 11/08/18. Therefore, the records do not support severe aortic regurgitation. In the setting of chronic severe aortic regurgitation, ventricular dilation and hypertrophy develop, which is not documented in this case. Many other conditions the patient has may also cause exertional dyspnea. There is no catheterization data to support that aortic regurgitation is a significant contributor as evidenced by elevated left ventricular end-diastolic pressure. Transcatheter aortic valve replacement has not been adequately evaluated for patients with primarily aortic regurgitation, as opposed to aortic valve stenosis. In sum, the superior efficacy of the requested heart surgery to correct the heart valve using a catheter (transcatheter valve repair) has not been established.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 65-year-old female enrollee has requested reimbursement for the repair of nasal vestibular stenosis performed on 7/28/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees chronic sinusitis. The physician reviewer found nasal valve collapse is a common cause of nasal airway obstruction. Although many techniques have been devised to correct the functional and aesthetic aspects of this problem, none have been demonstrated to be uniformly successful. One solution to the problem may lie lateral to the nasal valve angle in the fibroareolar tissue that connects the lateral aspect of the lateral crus to the bony pyriform aperture. Age-related or surgically induced weakening and loosening of these structurally important, fibroareolar connections can result in a prolapse of the lateral aspect of the lateral crural away from the pyriform margin and toward the septum with a consequent narrowing of the nasal valve region. This narrowing can lead to nasal obstruction. This patient had valve collapse and a positive Cottle maneuver. Thus, the vestibular stenosis repair should improve her nasal breathing. Accordingly, the repair of vestibular stenosis performed on 7/28/17 was medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 55-year-old male enrollee has requested authorization and coverage for esketamine (Spravato) nasal spray (code C9399), 68-84 mg intranasal for one month, then up to two times weekly. 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 the records indicate that the patient has a history of depression as well as anxiety. Progress notes indicate that the patient has had unsuccessful trials of electroconvulsive therapy and transcranial magnetic stimulation. The progress notes indicate the patient has had a long history of treatment-resistant depression, which appears to be an area where ketamine has been clinically indicated. Andrade noted that although big data on ketamine are presently unavailable, the drug holds promise in the treatment of depression, especially refractory depression. The progress notes indicate that the patient has had a positive response from esketamine in the recent past. Overall, the literature shows some mixed results with regards to ketamine treatment as well as a lack of long-term outcomes data and safety data. However, the patient has failed evidence-based treatments for treatment-resistant depression, including multiple medication trials, medication augmentation strategies, transcranial magnetic stimulation, electroconvulsive therapy and psychotherapy. There is sufficient support for the requested medication in this clinical setting. Therefore, esketamine (Spravato) nasal spray (code C9399), 68-84 mg intranasal for one month, then up to two times weekly is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 21-year-old female enrollee has requested reimbursement for knee arthroscopy synovectomy performed on 12/20/17. 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 Synovial plica are folds in the lining of the knee joint which are sometimes sources of painful abrasion against the medial femoral condyle.  The meta-analysis by Gerrard and Charalambous noted arthroscopic surgical management of symptomatic medial knee plica results in favorable outcomes. Our results suggest that arthroscopic surgical excision should be considered as a treatment modality in patients with pathological medial plica disease of the knee either as a first-line treatment or when symptoms have not responded to non-surgical interventions. Partial synovectomy for resection of symptomatic plica is a standard procedure. This patient had substantial knee pain despite nonsurgical treatment. Thus, knee arthroscopy synovectomy performed on 12/20/17 was likely to have been more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive patients with hepatitis C, genotype 1 infection, treatment with Harvoni is recommended.  Additionally, treatment of patients before they progress to cirrhosis is advantageous.  Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1
A 52-year-old male requested authorization and coverage for hypoglossal stimulator.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees obstructive sleep apnea. The physician reviewer found that the patient has been diagnosed with obstructive sleep apnea (OSA). The sleep study that is available is over eight years old and it shows only hypopnea events with no obstructive apnea events. The patient has failed Provent, CPAP, BiPAP, and dental device. The Inspire device is U.S. Food and Drug Administration approved for the treatment of OSA when certain criteria are met. However, this patients sleep study is over eight years old. As such, the documentation is lacking to support the superior efficacy of the requested services over the standard options available for treating this patients medical condition.

Therefore, for the reasons stated 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: Experimental
Decision: Upheld

Summary Reviewer 1

A 36-year-old female enrollee has requested reimbursement for AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who underwent open reduction and internal fixation. The physician reviewer found that the operative note dated 2/01/18 advises that a 10 mm and 12 mm 2.0 Synthes screw was utilized to fixate the fracture. The operative note indicated that excellent fixation and anatomic reduction was achieved. No other pathology was noted in the operative note that would require additional measures to improve healing. Furthermore, amniotic membranes and other graphs similar to this are authorized for the use of ulcerations of the skin. In this particular case, it was utilized in between a deep and superficial closure after a fracture fixation. While the literature on amniotic grafts do demonstrate promise when utilized for skin ulceration closure, there is a lack of support for the services at issue in this clinical setting. Therefore, AmnioMatrix or BioDMatrix injectable, 1 cc provided on 2/01/18 was not likely to have been more effective than other treatment options. Based upon the information set forth above, the services at issue were 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.

. The physician reviewer found that this patient is a 58-year-old male with a melanoma on his left anterior shoulder measuring .51mm Breslow depth. His provider sent a tissue sample for molecular genetic testing to help determine the risk of metastasis of the tumor. The patient has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17. The Health Insurer denied this request for reimbursement. Per the Health Insurer, the services at issue were considered investigational for the evaluation of this patients melanoma. There is a lack of formal standard procedures or precautions that would be changed in light of the data provided by these molecular testing. Currently, there is a paucity of evidence to support its use in this clinical setting. The DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. The test examines gene markers and then the lesion can be further stratified to tell if it is high risk for metastasis. This test has shown some accuracy determining risk of metastasis; however, decision-making based on the results of the test is indeterminate at this time. There is limited scientific evidence permitting conclusions concerning the effect of this test on health outcomes and there is not enough published data to support its routine use. The treatment of this patient would not change based on the results of the examination. Moreover, the test is not considered standard of care for treatment of patients in this clinical setting. Formal standard procedures or precautions that would be changed in light of the data is lacking. The current standard of care would be to perform a wide local excision. Since this test does not provide a superior benefit over established tests in terms of outcomes, DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17 was not likely to have been more beneficial for the evaluation of this patients medical condition than any available standard modalities. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 54-year-old male enrollee has requested reimbursement for the Prometheus diagnostic panel performed on 11/24/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Prometheus diagnostic panel performed on 11/24/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the article by Dontan the correlation between serologic markers and genetic variations may contribute to reclassifying IBD into new and more homogeneous subclasses. Their significance in diagnosing populations at risk, such as unaffected relatives of IBD patients and [Crohns disease] CD patients prior to diagnosis, is under current investigation. In sum, the reliance on marker testing to assess whether a patient has IBD, without definitive mucosal inspection and sampling is not the standard of care. All told, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.