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

Summary Reviewer 2


A 40-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/08/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found there is sufficient support for the service at issue in this patients case.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed on 9/08/16 was likely to have been more effective than other modalities for evaluating this patient.  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 2 
A 26-year-old female enrollee has requested reimbursement for myPath Melanoma test performed 
on 12/30/21. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds melanoma. The physician reviewer found 
that the records document that this patient has a history of  right lateral posterior shoulder 
melanoma. The patient underwent the myPath Melanoma test for further evaluation of her lesion. 
Per  the  American  Society  of  Dermatopathology,  appropriate  use  criteria  for  evaluation  of 
melanocytic lesions is of uncertain appropriateness for the vast majority of clinical scenarios 
(Fung, et al.). On review of the available documentation, this patients lesion did not require 
assessment with the myPath Melanoma test. In the clinical setting with findings that could be 
interpreted as ambiguous, the standard of care is to consult with another pathologist before 
reaching the conclusion that the histomorphologic findings are truly ambiguous and warrant an 
ancillary gene expression profiling test that is largely of uncertain clinical benefit. Therefore, the 
myPath Melanoma test performed on 12/30/21 was not likely to be more beneficial for evaluation 
of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 52-year-old female with a past history of long-term eating disorder, laxative abuse, chronic hyponatremia, hypercoagulable state treated with Pradaxa, and deep vein thrombosis who presented to the hospital in hypovolemic shock secondary to upper gastrointestinal bleed. She was hypotensive, with systolic blood pressure in the 60s and tachycardia. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was able to ambulate to the stretcher. There is no documentation of frequent turning of the patient or hourly fingerstick blood glucose levels. There is no documentation of the necessity for intravenous fluids or the necessity for intravenous medication. Furthermore, there is documentation that the patient has had treatment multiple treatments at this facility in addition to other facilities, but this is a facility that she was agreeable to. There is no documentation of exceptional factors supporting medical necessity for this facility rather than alternative facilities with closer geographic proximity. Therefore, A0426, A0430, A0435, A0434 for date of service 6/22/19 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 54-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 6/01/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.The physician reviewer found 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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this patients case, there were no problems to be solved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  There is a lack of support for the services at issue in this setting.  Thus, digital breast tomosynthesis performed on 6/01/15 was not likely to have been of greater benefit than other options for 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 27-year-old female enrollee has requested reimbursement and prospective authorization and coverage for acute inpatient psychiatric rehabilitation services provided from 9/3/15 forward. 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 schizoaffective disorder.  The physician reviewer found the patient is gravely disabled by her mental illness and has required multiple psychiatric hospitalizations. She had florid psychosis and planned to kill a family member. As such, a conservative hospitalization to improve her condition and prevent a more serious episode of illness was to be expected. Discharge prior to 9/28/15 would have been premature and more than likely would have resulted in undue morbidity, unnecessary risk to the community and prompt readmission as the illness burden that prompted the admission had not yet resolved. The patient had been described as labile, uncooperative, irritable, agitated, delusional, disorganized and homicidal. Convincing her to take medication was an arduous process. On 8/29/15, she was agitated, illogical and needed intramuscular administration of an antipsychotic medicine to address her psychosis. On 8/30/15, she was fixated on needing a vaporizer to deliver marijuana to temper her homicidality. On 8/31/15, she was refusing medication, hostile, aggressive and threatening. However, the psychiatric progress notes did reflect the emergence of durable improvement and by 9/28/15 there was no mention of medication changes, tolerability issues or non-adherence. The patients energy improved while her sedation waned. The patient consistently denied any suicidality, homicidal ideation or hallucinations. In addition, there was no report of disruptiveness on the unit. In the absence of any clinical documentation after 9/28/15, the patient had achieved a level of stability that would be conducive for ongoing specialty care in a less restrictive setting. All told, the acute inpatient psychiatric rehabilitation services provided from 9/3/15 through 9/28/15 were medically necessary for treatment of this patients medical condition, while services from 9/29/15 forward were not and are not medically necessary. In conclusion, 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: Overturned

Summary Reviewer 3 
 
A 59-year-old male enrollee has requested reimbursement for Guardant 360 testing performed 
on 3/31/21. The Health Insurer has denied this request and reported that the services at issue 
were  investigational  for  the  evaluation  of  the  enrollees  medical  condition.  The  physician 
reviewer found that The National Comprehensive Cancer Network guidelines state, The use of 
cell-free/circulating tumor DNA testing can be considered in specific clinical circumstances, most 
notably: in the initial diagnostic setting, if following pathologic confirmation of a non-small cell 
lung cancer diagnosis there is insufficient material for molecular analysis, cell-free or circulating 
tumor DNA should be used only if follow-up tissue-based analysis is planned for patients in which 
an oncogenic driver is not identified. In this case, the patient did not have sufficient material on 
the biopsy to evaluate for driver mutations. The medical evidence supports the services at issue 
in this clinical setting. For patients with advanced non-small cell lung cancer, liquid biopsy-based 
test is reliable as standard of care tissue testing. Therefore, Guardant 360 testing performed on 
3/31/21 was likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 52-year-old female enrollee has requested authorization and coverage for sclerotherapy. 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 in this case, the ultrasound report does not indicate the extent of involvement of the great saphenous vein (or the sizes) and also does not indicate if the saphenofemoral or saphenopopliteal junctions are involved. There is also no indication of the size of the veins. The short saphenous vein in particular is described as only having reflux in its cranial extension. Despite the above, sclerotherapy is clinically indicated in this clinical setting given the lack of other treatment options available.  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: Experimental
Decision: Upheld

Summary Reviewer 2

A 59-year-old female enrollee has requested reimbursement for arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. However, there are some exceptions to this rule. Patients with symptomatic meniscal tears and degenerative changes in the knee can benefit from arthroscopic meniscectomy, particularly if they are having mechanical symptoms such as locking. Similarly, a large loose body causing mechanical symptoms should be removed, even in the presence of osteoarthritis. Loose body removal has been proven to be more effective than conservative treatment for knee osteoarthritis. Therefore, the partial medial meniscectomy and loose body removal were medically necessary. The third procedure is abrasion chondroplasty, which has been denied. The role of arthroscopic debridement in the painful degenerative knee is controversial. Abrasion chondroplasty consists of shaving of fibrillated loose articular cartilage with a mechanical shaver. Studies have shown that such arthroscopic debridement for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. As such, arthroscopy, knee, surgical, abrasion arthroplasty (includes chondroplasty when necessary) or multiple drilling of microfractures performed on 8/16/19 was not likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 68-year-old male enrollee has requested reimbursement for the positron emission tomography (PET) scan performed on 2/3/15. The Health Insurer has denied this request indicating that the diagnostic procedure at issue is considered investigational for evaluation of the enrollees cognitive impairments, neuropsychiatric symptoms and parkinsonian features.  The physician reviewer found that in patients who have rapid cognitive decline or have symptoms that may mimic other neurodegenerative processes, PET scan is indicated to help differentiate between the conditions that are on the differential diagnosis. Molecular imaging with PET offers a broad variety of tools supporting the diagnosis of movement disorders. The more widely applied PET imaging techniques have focused on the assessment of neurotransmitter systems, predominantly the pre- and post-synaptic dopaminergic system. Additionally, PET imaging with fluorodeoxyglucose (18F) has been extensively utilized to assess local synaptic activity in the resting state and to highlight local changes in brain metabolism accompanying changes in neural activity in movement disorders. Given that the clinical documentation submitted for review, the PET scan performed on 2/3/15 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 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 47-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 4/02/16 through 4/27/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found there is a lack of support for the services at issue in this clinical setting.  Although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the residential level of care following detoxification.  Upon admission, the patient had a normal mental status examination.  He was well-groomed and cooperative.  His thought process was coherent.  His mood was normal while his affect was mood-congruent and appropriate.  He denied any psychiatric history, aside from anxiety and poor sleep.  He denied suicidal ideation and expressed motivation for recovery.  The records do not demonstrate that the patient had engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, community sponsorship, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate at the time.  Thus, substance use residential treatment provided from 4/02/16 through 4/27/16 was not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 70-year-old female enrollee has requested reimbursement for radiofrequency ablation of the right side performed on 5/25/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees varicose veins. The physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  There is a lack of documentation of a concerted effort to treat conservatively.  It is noted that the anatomy of the accessory vein was likely not amenable to endovenous ablation.  There is no evidence the patient was having activity limiting symptoms despite the use of compression stockings.  In sum, radiofrequency ablation of the right side performed on 5/25/16 was not likely to be more efficacious 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The  patient  is  a  43-year-old  male  with  ongoing  neck  pain.  The  patient  has  requested 
authorization and coverage for artificial disc arthroplasty. The physician reviewer found that the 
current medical evidence supports the medical necessity of the requested services in this clinical 
setting. Kim and colleagues performed a prospective study of patients treated with cervical disc 
arthroplasty for one-level and two-level pathology. The authors noted that the Results through 
10 years were comparable to seven-year outcomes, demonstrating that cervical disc arthroplasty 
with Mobi-C continues to be a safe and effective surgical treatment for patients with one- or two-
level cervical degenerative disc disease. The article by Gornet and colleagues supports the 10-
year efficacy of cervical disc arthroplasty compared to fusion surgery. In this case, the patient has 
nerve root compression from degenerative disc disease. There is sufficient support for the 
requested services in this setting. Therefore, the requested artificial disc arthroplasty is medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 21-year-old female enrollee has requested reimbursement for substance abuse residential services provided from 5/15/19 through 5/16/19. 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 the American Society of Addiction Medicine (ASAM) criteria for level of placement can be applied to the patients presentation to help determine whether the patient met criteria for residential care. With regards to dimension 1, acute intoxication and/ or withdrawal potential, the patient met this criteria due to withdrawal symptoms. In terms of dimension 2, biomedical condition and complications, the patient met this criteria due to active medical issues. With regards to dimension 3, emotional/behavioral or cognitive conditions and complications, the patient met this criteria due to anxiety and suicidal ideation. In terms of dimension 4, readiness to change, the patient met this criteria. With regards to dimension 5, relapse, continued use, or continued problem potential, the patient met this criteria based on the records. In terms of dimension 6, recovery/living environment, the patient also met this criteria per the clinical notes. Therefore, ASAM criteria were met for residential care. Thus, substance abuse residential services provided from 5/15/19 through 5/16/19 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 64-year-old male with a diagnosis of hypogonadism since 2011. In a letter dated 1/21/16, the provider notes the patients symptoms include decreased libido, decreased energy, mood swings, fat accumulation, sleepiness, and reduced muscle mass. The patient has been treated with Testopel since August 2015. On 3/16/16, his testosterone level was 187. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The Testopel implants provided on 1/21/16 and 5/26/16 were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Testosterone replacement therapy (TRT) is recommended for older men with either low serum testosterone or low testosterone plus accompanying symptoms of hypogonadism. Serum testosterone levels of less than 300 is considered to be low, and testosterone levels of less than 250 is considered to be frank hypogonadism. Most experts support TRT for older men with frank hypogonadism and symptoms. TRT produces a number of established benefits in hypogonadal men, including increased muscle mass and strength, decreased fat mass, increased bone mineral density, and improved sexual function. In this case, the services at issue were 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 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 2

A 61-year-old female has requested authorization and coverage for 64568, 0466T and 95970. 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 this patient has severe obstructive sleep apnea and has not been able to tolerate the CPAP device. She has septal deviation. She had a sleep endoscopy which showed anteroposterior collapse and minimal lateral collapse. The Inspire device has been approved by the U.S. Food and Drug Administration for the treatment of obstructive sleep apnea. However, the patient has septal deviation which has not been treated surgically, and this can improve her ability to tolerate the CPAP device. At this point, she is not a candidate for the Inspire device. There is a lack of support for the requested services in this clinical setting. Thus, the requested services (64568, 0466T and 95970) are not likely to be of greater benefit 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.