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

Summary Reviewer 3

A 22-year-old female enrollee has requested reimbursement for burn wound treatment provided on 1/10/19 (CPT 15273, 15274, 15277 and 15278). The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports a portion of the services at issue. Patients with burns benefit from early debridement and facilitation of rapid re-epithelialization (ideally less than three weeks) to prevent hypertrophic scar and the development of contractures and other adverse sequelae. While skin grafts have long been the gold standard for burn treatment, skin substitutes have a well-established role in the treatment of superficial and some deep partial thickness burns. Suprathel is a fully synthetic porous membrane that conforms to the underlying wound bed and promotes epithelialization. For partial thickness burns, Suprathel is superior to skin grafting since it avoids a donor site and significant pain. The ability to heal the wound and the ultimate appearance of the healed wound are equivalent to standard of care. For full thickness burns, however, it is inappropriate to use Suprathel. In this case, Suprathel was used on both partial and full thickness burns. Thus, burn wound treatment (CPT 15273, 15274, 15277 and 15278) for the partial thickness burns provided on 1/10/19 was likely to have been more beneficial than other treatment options. However, the superior efficacy of burn wound treatment (CPT 15273, 15274, 15277 and 15278) for the full thickness burns has not been established.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A  49-year-old  male  enrollee  has  requested  authorization  and  coverage  for  intraosseous 
basivertebral nerve ablation. The Health Insurer has denied this request and reported that the 
requested service is investigational for the treatment of the enrollees chronic low back pain. At 
issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial for 
treatment of the enrollee's condition than any available standard therapy. The physician reviewer 
found that in a randomized control trial evaluating the effectiveness of intraosseous radiofrequency 
ablation of the basivertebral nerve to standard care for the treatment of chronic low back pain in a 
specific subgroup of patients suspected to have vertebrogenic related symptomatology, Khalil and 
colleagues noted that the study showed clear statistical superiority for all primary and secondary 
patient-reported outcome measures in the radiofrequency ablation arm compared with the standard 
care arm. The authors noted that in comparing the radiofrequency ablation arm to the standard 
care arm, there were statistically significant improvements in Oswestry Disability Index (ODI) 
scores and in Visual Analogue Scores (VAS) in the treatment arm compared to the standard of 
care arm.  In a study reporting on the two-year clinical outcomes for patients with chronic low 
back  pain  treated  with  radiofrequency  ablation  of  the  basivertebral  nerve,  Fischgrund  and 
colleagues noted clinically meaningful improvements in both ODI and VAS sustained at two years 
following treatment. Lorio and colleagues note that guidelines by the International Society for the 
Advancement of Spine Surgery support the use of intraosseous ablation of the basivertebral nerve 
for chronic low back pain for patients who have had chronic low back pain for at least six months, 
have tried and failed six months of non-surgical management, and demonstrate Modic changes on 
at least one endplate on magnetic resonance imaging (MRI). In this case, the patient has a history 
of several years of persistent non-radicular chronic low back pain that has been refractory to 
multiple modes of standard care including physical therapy, medications, spinal injections of the 
facet joints, medial branch nerves, and epidural steroid injections. In this clinical setting, current 
medical literature supports the Intracept procedure as superior to standard care both in improving 
pain scores and disability scores, with results lasting for at least two years. Therefore, intraosseous 
basivertebral nerve ablation is likely to be more beneficial for treatment of the patients condition 
than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old male enrollee has requested authorization and coverage for Repatha. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees hyperlipidemia. The physician reviewer found that this patient has been diagnosed with hyperlipidemia, documented obstructive coronary disease and documented inability to tolerate statin therapy. However, there is no reported trial or intolerance to ezetimibe. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. Since ezetimibe has been demonstrated to be safe, well-tolerated, effective at lowering LDL cholesterol, and associated with improved outcomes, it is medically appropriate to trial this medication prior to determining the need for a PCSK9 inhibitor such as Repatha.  Repatha is not medically indicated at this time since the need for additional LDL lowering has not been documented while on ezetimibe. All told, Repatha is not medically necessary for the treatment of this patient. Therefore, 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: Upheld

Summary Reviewer 1


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 in contrast to acute urticaria, many cases of chronic urticaria have identifiable causes.  According to current management guidelines for chronic urticaria, chronic autoimmune urticaria can be differentiated from idiopathic urticaria by the presence of auto-antibodies to IgE receptors, also named chronic urticaria index.  The Chronic Urticaria (CU) Index is available from reference laboratories. Patients with a chronic urticaria and a positive functional test result for autoantibody to the immunoglobulin E (IgE) receptor, likely have an autoimmune basis for the diagnosis. The evaluation for an autoimmune process is necessary to identify non-allergic triggers for her symptoms.   The implication of such distinction has direct impact on the choices of treatment, as to include immune modulating or suppressor agents in addition to the conventional antihistamines for the treatment of chronic urticaria. The presence of urticarial symptoms in this patient has been greater than two months and is considered chronic urticaria. Furthermore, the treating provider also determined that the cause of her chronic urticarial symptoms was unlikely to be allergic. Therefore, an evaluation for autoimmune causes is clinically reasonable and necessary. In conclusion, the service in review (CPT code 86343 - leukocyte histamine release test) is likely to be more beneficial for treatment of the enrollees medical condition than any available standard of care. Based upon the information set forth above, the services at issue were 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 

A 30-year-old male enrollee has requested reimbursement for substance use residential treatment provided from 7/04/18 through 7/20/18. 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 that the submitted documentation supports the medical necessity of a portion of the services at issue. The patients abuse of alcohol was impairing his daily routine and contributing to significant impairment across multiple domains of functionality. As such, specialty care was indicated. However, the patient completed an uncomplicated detoxification.  He was maintaining sobriety and was motivated for recovery. His girlfriend was supportive. He had safe housing. Despite his comorbid obsessive-compulsive disorder, the patient did not have a psychiatric condition or medical illness that required placement at the residential level of care. Further, the patient had no history of chemical dependency treatment, such as sponsored community programming, outpatient counseling, anti-craving medication, intensive outpatient services, partial hospitalization or placement in a sober living environment.  This is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that similarly comprehensive, evidence-based services provided a less restrictive treatment setting for this stable, motivated and otherwise healthy patient would have been insufficient or inadequate at the time. With that said, discharge on a federal holiday would have incurred a needless gap in treatment and thus would have been inappropriate. The extra day also afforded opportunity to address his severe craving, as it appears that acamprosate was added the following day. On 7/05/18, the patients craving was mild. There was no mention of medication intolerability or non-adherence. His appearance was appropriate, and he had no impairment in memory, concentration or thought processing. In sum, the patient had improved with the treatment intervention. He was autonomous and was maintaining motivation for sobriety. Further, he had not failed a less restrictive treatment course during the episode of illness. As such, the substance abuse residential treatment services at issue were no longer medically necessary as of 7/05/18. Thus, substance use residential treatment provided on 7/04/18 was medically necessary, but not thereafter. Therefore, a portion of the services at issue was medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 40-year-old female enrollee has requested reimbursement for Decision Dx melanoma gene assay performed on 10/15/15. The Health Plan has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk of recurrence in cutaneous melanoma. The physician reviewer found that in general, Decision Dx test is not the standard of care for evaluation of melanoma. In this case the patient presented with a thin melanoma of 0.81 mm with poor prognostic compounding factors of ulceration, mitoses, and regression seen on pathology. Typically, when a melanoma is thin, no further testing is required as the risk of spread is low.  However, when a tumor shows mitoses and ulceration it can mean an aggressive histology and further testing like a sentinel lymph node biopsy (SNLB) can be indicated. A SNLB is an invasive procedure and does not provide as much information about risk of tumor metastasis as the Decision Dx test. Therefore, testing was medically reasonable for this patient with a thin melanoma and multiple unique features. All told, the Decision Dx melanoma gene assay performed on 10/15/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues.  The physician reviewer found that the documentation provided does not support the medical necessity for the services at issue in this clinical setting.  By the time of the patients admission on 9/26/16, her last use of alcohol was on 9/21/16.  Although she was said to have experienced a seizure with subsequent hospitalization, there were no medical records provided from which to ascertain the nature and severity of this seizure or the treatment of same.  On admission to detoxification, she was not on any prophylactic anticonvulsant medication.  The patient did not demonstrate any post-acute withdrawal symptoms described in either the history and physical, or the psychiatric evaluation.  She was not a danger to herself or others.  There were no emotional, behavioral, cognitive, or impulsive factors requiring inpatient detoxification level of care.  She was not agitated, manic, or psychotic.  She suffered from hypertension and hyperlipidemia. However, neither these medications nor did the upwards titration of Lexapro, required inpatient monitoring.  She was underweight at 104 pounds but this was not a life threatening situation requiring 24 hours per day, seven days per week monitoring with medical, nursing, and dietary professionals.  The patient has a history of an extended period of sobriety, with Alcoholics Anonymous attendance. There is no evidence to suggest that she could not have continued her recovery at an ambulatory level of care.  Based on the records provided, this patient did not require 24 hours per day, seven days per week monitoring. As such, reimbursement for substance abuse inpatient detoxification and residential services provided from 9/26/16 through 10/20/16 were not medically necessary for the treatment of this patient. Therefore, based on the reasons stated above, the services at issue were not medically necessary for treatment of this patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 42-year-old female with a history of chronic low back pain and numbness in her legs. Imaging studies have revealed grade 2 isthmic spondylolisthesis at L4-5 associated with severe bilateral neural foraminal narrowing, severe disc degeneration, and facet hypertrophy. The patient has failed non-operative treatment, including physical therapy, chiropractic care, home exercise program, analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and bracing. The provider has advised laminectomy and facetectomy/decompression, and posterior lumbar interbody fusion at L4-5 with instrumentation. The physician reviewer found that the lumbar isthmic spondylolisthesis in adults is defined as the forward translation of a lumbar vertebra on top of another, resulting from a defect in the pars interarticularis. The spondylolisthesis can be graded by the degree of slip, which in this case is grade 2 or more than a quarter but less than a half of the diameter of the vertebral body. There is a history of chronic low back pain and sensory neurological deficit in the lower extremities, with imaging evidence of severe bilateral neural foraminal narrowing in the same distribution. There is severe degeneration of the L4-5 intervertebral disc and Modic type 2 endplate changes. The persisting low back pain and evidence of radiculopathy, corroborated by imaging studies, are indications for surgery. This is supported
by the medical literature. The surgical fusion requested is posterior lumbar interbody fusion, which is also supported by the literature. The study by Alhammoud and colleagues did not find any significant differences between anterior and posterior approaches to fusion of the lumbar spine for isthmic spondylolisthesis. The article by Noorian also supports surgery and discusses various surgical options. Therefore, the requested posterior lumbar interbody fusion at L4-L5 and one inpatient bed day are medically necessary for the treatment of this patient.[insert ANALYSIS AND FINDINGS]
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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 this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. 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. In sum, gene testing provided on 9/26/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 41-year-old male has requested reimbursement for a wearable cardioverter defibrillator. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees non-ischemic cardiomyopathy. The physician reviewer found there is a lack of support for the device at issue in this clinical setting. The current medical literature does not support an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in the treatment of a newly diagnosed non-ischemic cardiomyopathy prior to 90 days of guideline-directed medical therapy.  The device at issue was not likely to have been of greater benefit than any available standard therapy, which would include beta blockers, angiotensin receptor blockers and diuretics. The current standard of care requires 90 days of such therapy followed by a reassessment of ejection fraction. During the dates of service in dispute, this patient had not been medically treated for non-ischemic cardiomyopathy for 90 days.  In sum, the wearable cardioverter defibrillator was not likely to have been superior over other treatment options.  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: Overturned

Summary Reviewer 

A 42-year-old female enrollee has requested reimbursement for hip arthroscopy performed on 4/05/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that this patient underwent right hip arthroscopy on 4/05/18 for revision treatment of femoroacetabular impingement and synovial cyst. She was status post three prior right hip arthroscopic procedures for treatment of femoroacetabular impingement, labral tear, and synovial cyst, with persistent and worsening right hip pain. Functional limitations were documented in activities of daily living. Clinical examination findings were consistent with MRI evidence of a synovial mass, possible labral tearing, and mixed femoroacetabular impingement, and x-ray evidence of Tonnis grade 1 changes. She had tried and failed extensive conservative management, including activity modification, physical therapy, home exercise, injections, and NSAIDs. Surgery was recommended to include revision hip arthroscopy for lysis of adhesions, decompression of her femoroacetabular impingement, evaluation of her cartilage, and removal of lesion anterior to her hip joint. Operative findings confirmed mixed femoroacetabular impingement with subspine component, labral deficiency, loose bodies, synovial cyst, and chondromalacia of the anterior superior acetabulum and femoral head. Current evidence based medical guidelines support arthroscopic hip revision surgery for residual femoroacetabular impingement for functional outcome improvement, including Cam decompression, identification and treatment of subspine impingement, labral preservation/reconstruction, and capsular preservation/plication. Therefore, hip arthroscopy provided on 4/05/18 was medically necessary for the treatment of this patient. Therefore, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 30-year-old female enrollee has requested authorization and coverage for Adderall XR 90 mg daily. The Health Insurer has denied this request indicating that the requested medication dosage is considered investigational for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). The physician reviewer found according to the U.S. Food and Drug Administration (FDA) approval for Adderall XR, there is no proven benefit with doses above 60 mg in adults with ADHD. The provider notes that the patient has been stable on a dose of Adderall XR 90 mg daily for seven years. High dose stimulants can be risky for substance induced psychosis, mania, anxiety and can also contribute or worsen cardiac conditions. All told, the requested Adderall XR 90 mg daily is not 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 medication dosage is 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.