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

Summary Reviewer 


A 43-year-old female enrollee has requested reimbursement for residential treatment center services provided from 5/27/17 through 6/26/17. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, as of 5/27/17, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm score is two (2), low risk of harm. The patient does not have any prior history of suicide attempts. On admission, the patient did not have any suicidal ideation. The patient was able to care for herself. The patient did not have any legal problems. The patients functional status score is three (3), moderate impairment. The patients substance use led her to lose her job. She was unable to fulfill responsibilities and obligations in her job. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, depression, migraine headaches, and hypertension. The patients recovery environment score is two (2), mildly stressful environment. The patient is single and has two children, ages 10 and 13. Potential for alcohol exposure exists at her home. The patients level of support score is two (2), supportive environment. The patients parents are supportive of the patient. The patient also has community support in Alcoholics Anonymous. The patients treatment history score is three (3), moderate response to treatment and recovery. The patients prior treatments have been modestly successful. She had obtained five months of sobriety prior to the residential treatment center admission. The patient also had 70 days of sobriety while receiving treatment as an outpatient. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient was motivated for recovery and cooperative with staff. She would accept and participate in treatment. Based on these criteria, the patient had a total score of 17 and met criteria for an intensive outpatient program (IOP). Therefore, the residential treatment center services provided from 5/27/17 through 6/26/17 were not medically necessary for treatment of the patients medical condition. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 78-year-old female enrollee has requested authorization and coverage for positron emission tomography (PET) imaging and magnetic resonance imaging (MRI) of the bilateral breasts. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested MRI of the bilateral breasts.  The literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  MRI studies of the breast are highly sensitive, but have a relatively low level of specificity.  In this particular patient, the medical evidence does not support MRI of the bilateral breasts.  The only indicator in this patient that something might be amiss is the elevated tumor marker.  While breast MRI is becoming increasingly commonplace, there is insufficient data available to support its use as a routine screening study in patients with a relatively average risk of developing breast cancer. However, there is sufficient support for the requested PET imaging in this clinical setting.  In this case, since the elevated tumor marker was identified, and the referring provider believed it was necessary to explore the possibility of recurrence, simple imaging was performed.  The CT scan and the bone scan were inconclusive.  Advanced imaging such as PET scanning may be warranted for patients in which conventional imaging is inconclusive.  If further investigation of the elevated tumor marker is felt to be clinically indicated, PET scan is appropriate.  Although the small lesions seen in the lung bases are likely too small to be metabolically active, there is some value in searching for other sites of occult tumor such as the bones.  In sum, the requested PET imaging is medically necessary.  However, the requested MRI of the bilateral breasts is not medically indicated for the evaluation of this patient.  Therefore, a portion of the requested services is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 62-year-old male enrollee has requested authorization and coverage for patent foramen ovale (PFO) closure. 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 had a recent transient ischemic attack while flying on an airplane. He was evaluated and has no other reason for transient ischemic attack other than the patent foramen ovale. In addition, the development of the transient ischemic attack symptoms while flying a high altitude makes the patent foramen ovale an even more likely etiology of the symptoms as right heart pressures increase at high altitudes, and the risk of transient deep vein thrombosis is higher as well. This combination (occult deep vein thrombosis with elevated right heart pressures because of lower air pressures) makes the likelihood of paradoxical embolism from increased right to left shunting significantly higher in the setting of a large patent foramen ovale. This adds further credence to the clinical suspicion of the patent foramen ovale being the culprit pathology of the transient ischemic attack in this case. Recent data and meta-analyses suggest that patent foramen ovale closure prevents recurrent crytogenic stroke better than medical therapy alone in patients with no other suspected cause of the stroke and likely transient ischemic attacks as well. Therefore, patent foramen ovale closure is likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3   
A 28-year-old female enrollee has requested reimbursement and prospective authorization and 
coverage for ketamine infusions from 9/07/21 forward. The Health Insurer has denied this 
request and reported that the services at issue were and are investigational for the treatment of 
the enrollees medical condition. The physician reviewer found that the records note multiple 
failed  trials  of  antidepressants,  augmentation  agents,  psychotherapies,  and  transcranial 
magnetic stimulation. The patient needed a residential level of care prior to ketamine infusion. 
After ketamine treatment, she was able to be discharged to the outpatient level of care and has 
had symptomatic and functional improvement. For patients with severe, treatment-resistant, 
unipolar, major depression without psychotic features who decline electroconvulsive therapy, 
ketamine is a reasonable alternative to antidepressants. Ketamine may be particularly helpful for 
patients with refractory, active suicidal ideation. Evidence supporting short-term use of ketamine 
for severe, treatment-resistant, unipolar, major depression without psychotic features includes 
multiple analyses of randomized trials that consistently demonstrate ketamine can rapidly 
improve depression for a relatively short period of time, and that the drug is relatively well-
tolerated. Thase and Connolly noted, Randomized trials have demonstrated that intravenous 
ketamine and intranasal esketamine can each rapidly improve treatment-resistant depression, 
including symptoms of suicidal ideation. Per the authors, For unipolar major depression, the 
efficacy of esketamine and ketamine appear to be comparable. However, no head-to-head trials 
comparing the two drugs have been published. Given that this patient has responded to her 
current treatment regimen of ketamine, it is appropriate to continue with this treatment rather 
than subjecting her to a trial of esketamine as an alternative. The medical evidence supports the 
services at issue in this clinical setting. Therefore, ketamine infusions from 9/07/21 forward were 
and are likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 62-year-old female enrollee has requested reimbursement for genetic testing performed on 7/31/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation for the evaluation of the enrollees medical condition. The physician reviewer found that the DecisionDx-Melanoma test is a clinically validated prognostic tool for patients with stage 1A disease, who are not recommended for sentinel node biopsy. Traditional clinical pathologic assessment for determination of prognosis based on tumor size, and histopathologic features as described in this patients biopsy report, underreport a significant percentage of stage 1 and 2 patients who subsequently present with recurrent disease and metastases with incurable melanoma. The DecisionDx-Melanoma test has been used as a standard method for prognosis assessment, based on multiple publications detailing the test utility in melanoma patients. The DecisionDx-Melanoma test is an independent predictor of risk. In sum, testing (DecisionDx-Melanoma Gene Assay) performed on 7/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 29-year-old female who presented to the emergency department on 6/6/22 with clinical 
and radiographic appendicitis. An operative report dated 6/7/22 reported a diagnosis of acute 
appendicitis. The physician reviewer found that at issue is whether inpatient hospital charges from 
6/6/22 through 6/7/22 were medically necessary for the treatment of this patient. The submitted 
documentation supports the medical necessity of the services at issue. Moris and colleagues note that 
the clinical diagnosis of acute appendicitis is based on history and physical, laboratory evaluation, and 
imaging, and that appendectomy remains first-line therapy for acute appendicitis, but treatment with 
antibiotics rather than surgery is appropriate in selected patients with uncomplicated appendicitis. In 
this case, the patient had clinical and radiographic appendicitis, and an appendectomy, the preferred 
treatment, was appropriately recommended and performed. A pathology report confirmed appendicitis. 
In this clinical setting, given the patients acute illness with unplanned surgery for acute appendicitis, the 
service at issue was medically indicated. Therefore, inpatient hospital charges from 6/6/22 through 
6/7/22 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested authorization and coverage for real-time intra-fraction target tracking for planned proton beam radiotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees craniopharyngioma status post resection.  The physician reviewer found that based on the medical records, the tumor was in intimate contact with the optic apparatus. The organ surface is at risk for harboring microscopic disease. The optic apparatus needs to be radiated in order to maximize the effectiveness of radiation therapy in disease control. However, avoiding the optic apparatus is not needed and the requested real-time intra-fraction target tracking for planned proton beam radiotherapy 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, I have determined 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: Overturned

Summary Reviewer 1 
 
A 60-year-old female enrollee has requested authorization and coverage for percutaneous or 
endoscopic spinal surgery. 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 has been treated for spinal stenosis, lumbar region with 
neurogenic claudication; chronic pain syndrome; complex regional pain syndrome I of left lower 
limb; and post- laminectomy syndrome. She presented with worsening low back pain. There is 
current evidence-based medical literature support for the use of this procedure for the treatment of 
spinal stenosis, as compared to lumbar epidural steroid injection. However, in this case, there are 
no clinical examination findings documented and no clear  discussion to  support minimally 
invasive surgery over standard lumbar decompression in the setting of thickening of the ligament 
flavum,  bilateral  foraminal  protrusions,  cross-sectional  area  of  the  central  canal  measuring 
approximately 50 square mm, severe canal stenosis and bilateral lateral recess stenosis, which 
cannot typically be fully addressed with minimally invasive surgery. Therefore, percutaneous or 
endoscopic spinal surgery is not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 61-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees colorectal cancer with liver metastases. The physician reviewer found that the American Society for Radiation Oncology (ASTRO) acknowledges the need for proton therapy when strongly justified by a dosimetric rationale such as specific dose-volume parameters for the target and nearby structures. Pelvic malignancies including gastrointestinal carcinomas are currently being evaluated and comparative efficacy evidence is being developed. In order for toxicity risks to be reduced, there should be a clinically significant reduction in dose to critical structures, with an evidence basis of benefit with dose reduction. However, the case records do not adequately demonstrate the need for proton therapy using dosimetric evidence. This is important in justifying the need for proton therapy in clinical scenarios for which proton therapy is not considered the standard of care. There is no documentation that a conventional three-dimensional (3D) conformal plan or intensity modulated radiation therapy (IMRT) would be unacceptable. All told, the requested proton beam radiation therapy 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 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 3

A 53-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. 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 melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that Femoroacetabular impingement is recognized as a common cause of hip pain resulting from abnormal contact between the proximal femur and acetabular rim. Abnormalities can be identified on either the femoral or acetabular side, but are most commonly seen on both sides. Harris and colleagues demonstrated that surgical treatment is effective and recommended in patients who fail to improve with routine conservative therapy. In this case, the patient is a physical trainer who performed activity modification and independent exercise, underwent chiropractic care, and was treated with nonsteroidal anti-inflammatory medications and opioid pain medications. The 4/23/16 magnetic resonance imaging (MRI) was interpreted as demonstrating moderate to high grade cartilage loss, but that appears to have been an overestimate based on the preoperative x-rays and operative findings documented in the surgical report. The 4/26/16 x-rays did not reveal substantial cartilage space narrowing. All told, the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16 was 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: Overturned

Summary Reviewer 2


The parent of a 12-year-old female enrollee has requested authorization and coverage for surgery (ApiFix procedure). The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. At issue is whether the requested services are likely to be more beneficial for treatment of the enrollees condition than any available standard therapy. The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the requested services in this setting. Stadhouder and colleagues noted, The use of the unilateral peri-apical concave self-distracting ratchet rod initially was associated with promising clinical and radiographic results. However, no distraction was observed and the high rate of serious adverse events within 2 years was considered to be unacceptable for further clinical application of this device in our institution, despite recent FDA approval. Cheung and colleagues noted, Various emerging techniques in the surgical treatment of idiopathic scoliosis in children and adolescents have demonstrated promising results in the reported data thus far. However, longer term prospective studies with larger cohorts are necessary to better evaluate their safety and efficacy. This patient has been diagnosed with adolescent idiopathic scoliosis. She had presented in consultation for scoliosis. She had not had any scoliosis intervention. She has been wearing her brace. Clinical and radiographic findings evidence a significant probability of ongoing major spinal curve progression. However, overall published quality, peer-reviewed literature does not support or evidence the request to be an effective and/or safe treatment for adolescent idiopathic scoliosis. Further studies are needed to adequately demonstrate the overall safety and/or efficacy of the requested ApiFix. Therefore, the requested surgery (ApiFix procedure) is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The patient is a 66-year-old male with a history of lower extremity swelling, hypertension, coronary artery disease, and hyperlipidemia. A lower extremity venous mapping ultrasound on 6/13/17 demonstrated no evidence of deep vein thrombosis (DVT). The bilateral greater saphenous veins were ablated. The right short saphenous vein was 4.2 mm with four seconds of reflux. A right medial distal calf perforator was noted with reflux. The left short saphenous vein was 7.5 mm with three seconds of reflux. There was a left medial distal calf perforator noted with reflux. Based on these results, the plan was for radiofrequency ablation (RFA) of bilateral short saphenous veins with RFA of bilateral medial distal calf perforators and ultrasound-guided sclerotherapy of varicose vein tributaries. The patient was treated with compression stockings. On 8/11/17, the provider noted the patient reports leg pains, achiness in the legs, night cramps, restless legs, leg swelling, and chronic skin color changes. The patients symptoms are interfering with his ability to perform activities of daily living. On physical examination, no clubbing or cyanosis is noted. There is bilateral ankle edema, left greater than right. The patient has requested authorization and coverage for endovenous vein ablation. The Health Insurer has denied this request indicating that the requested services are considered investigational. The documentation does not demonstrate that this patients current symptoms are due to his short saphenous vein reflux. The patient has not been reevaluated since he was treated with compression stockings and there is no documentation that he has been using them regularly. Moreover, there is no documentation of adequate lower extremity arterial perfusion in this patient with a history of coronary artery disease, hyperlipidemia, hypertension, and leg pain. Given these findings, the requested endovenous vein ablation 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 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.