Persius/imr-appeals huggingface dataset:
Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for exome sequence analysis (81415) provided on 8/15/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that the Society for Maternal-Fetal Medicine indicates that routine use of prenatal sequencing as a diagnostic test is not currently supported due to insufficient validation data and knowledge about its benefits and pitfalls. Although the technology is promising in genetic evaluation of an anomalous fetus, many challenges remain for the routine clinical use of exome sequencing. Interpreting results from exome sequencing is a very lengthy process, and is challenging due to reliance on phenotypic data that may be incomplete. Additionally, there are many counseling and ethical issues related to prenatal exome sequencing, including determining when to report secondary or incidental findings, the ongoing need for reanalysis of results, and the challenges of interpreting results in meaningful ways for patients. Therefore, given the complexities involved in interpretation of results, timeliness of results, and patient/family counseling, the decision to proceed with this type of testing should be made in consultation with a provider specializing in genetic testing, such as a certified genetic counselor or medical geneticist and is currently not the standard of care or medically necessary as in this case. Thus, CPT 81415 (exome sequence analysis) performed on 8/15/19 was not medically necessary for the evaluation of this patient.
Summary Reviewer 3
A 58-year-old male has requested authorization and coverage for proton beam therapy (77499). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees right tonsillar cancer. The physician reviewer found that currently, there is a lack of clinical data in the medical literature to suggest that treatment with proton beam therapy offers a clinical benefit compared to conventional radiation therapy techniques for tumors of the head and neck area. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy. A recent comparative analysis by Sio and colleagues found no significant difference in symptom burden in the acute and chronic phases of treatment with proton beam therapy when compared to photon therapy for head and neck cancer. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton therapy for the treatment of head and neck cancer. Thus, the superior efficacy of the requested proton beam therapy (77499) has not been established in this patients case. 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.
Summary Reviewer 

A 50-year-old male enrollee has requested authorization and coverage for Korlym 300 mg tablets. 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 current medical evidence supports the requested medication in this clinical setting. Meningiomas are more commonly positive for progesterone receptors than for estrogen receptors. Several studies have been conducted on long-term oral therapy of unresectable meningiomas with the antiprogesterone mifepristone (RU486). In the study by Grunberg and colleagues, fourteen patients received mifepristone in daily doses of 200 mg for periods ranging from two to greater than 31 months (greater than or equal to six months in 12 patients). Five patients demonstrated signs of objective response (reduced tumor measurement on computerized tomography scan or magnetic resonance imaging, or improved visual field examination). Three patients experienced subjective improvement (improved extraocular muscle function or relief from headache). The side effects of long-term mifepristone therapy were noted to have been mild. The authors noted that long-term therapy with mifepristone may have efficacy in cases of unresectable benign meningioma. There is sufficient support for the requested medication in this clinical setting. Therefore, Korlym 300 mg tablets are medically necessary for the treatment of this patient.
Summary Reviewer 


A 57-year-old female enrollee has requested reimbursement for the hysterectomy performed on 1/16/17. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees post-menopausal bleeding. The physician reviewer found that the records provided for review document that this patient presented with a history of post-menopausal bleeding that interfered with her activities of daily living and did not responded to medical management. Per the American College of Obstetricians and Gynecologists (ACOG), late peri-menopausal patients may be treated with cyclic progestin therapy, low-dose oral contraceptive pills, the levonorgestrel intrauterine device (IUD), or cyclic hormone therapy. The ACOG further noted that women who have completed childbearing, in whom medical therapy has failed, or who have contraindications to medical therapy are candidates for hysterectomy without cervical preservation. Appropriate treatment includes an endometrial ablation or hysterectomy. Endometrial ablation is not definitive therapy and is generally considered for premenopausal women. This patient was treated with conservative management, which was hormonal therapy appropriate for her age. Given the ACOG recommendations for patients who have failed conservative therapy in this clinical setting, the hysterectomy performed on 1/16/17 was medically necessary for treatment of this patients post-menopausal bleeding. 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.
Summary Reviewer 3

A 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. 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 support for a portion of the services at issue. This patient has painful varicose veins bilaterally. She is status post radiofrequency ablation of left great saphenous vein and ultrasound-guided foam sclerotherapy. There is support for the requested services for the left leg. For the left leg, the veins are residual after a prior thermal ablation. She continues to be symptomatic. Thus, the requested services for the left leg are likely to be superior over other treatment options. With regards to the right leg, the varicose veins are de novo. There is no saphenofemoral junction or saphenopopliteal junction reflux. Per the medical evidence, endovenous thermal ablation is preferred to surgery and foam sclerotherapy in the treatment of small saphenous vein incompetence. In sum, the requested foam sclerosant/endovenous ablation of the left leg is likely to be of greater benefit than other treatment options.
Summary Reviewer 2

The patient is a 64-year-old female with severe obstructive sleep apnea. The medical records document a history of unsuccessful attempts to utilize the gold standard treatment of continuous positive airway pressure (CPAP) therapy. On 9/12/17, the records noted a body mass index of 20.2. On 9/26/17, septoplasty and bilateral inferior turbinate reduction was performed. On 10/12/17, a home sleep study confirmed that the patient had a total of 162 obstructive apnea episodes, without central apnea. The documentation noted an apnea-hypopnea index of 43.0 episodes per hour of sleep. The patient has requested coverage for an implanted nerve stimulator. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of this patient.  There is sufficient support for the requested device in this clinical setting. This patient meets clinical criteria for consideration of surgical management of her obstructive sleep apnea symptoms. Prior evaluation has documented the degree of obstructive sleep apnea to be severe. The patient had trialed CPAP therapy for airway management and was intolerant to the use of this device. Clinical studies indicate that patients only benefit from this device when they have a body mass index less than 32, and the patient meets this criteria. Per the medical evidence, patients achieve a definite benefit from the implantation and electrical stimulation of the hypoglossal nerve for treatment of this disorder. All told, the requested implanted nerve stimulator is likely to be superior over other available treatment options. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 3

A 41-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/26/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that 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 testing 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. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Therefore, DecisionDx-Melanoma testing performed on 5/26/20 was not likely to have been more beneficial than any available standard therapy.
Summary Reviewer 2

A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that this patient has a history of cardiac sarcoidosis and symptomatic 2:1 atrioventricular block in need of pacemaker placement. In this circumstance of cardiac sarcoidosis and ejection fraction greater than 35% with an indication for pacemaker placement, it is reasonable to implant a defibrillator if meaningful survival of greater than one year is expected. Some patients with cardiac sarcoidosis with normal ejection fraction and no heart failure symptoms have high arrhythmic event rates, especially when late gadolinium enhancement is identified on cardiac MRI or abnormal findings are seen on cardiac PET imaging, such as this patient. The medical evidence supports the requested device in this case. Therefore, the requested cardioverter defibrillator is likely to be of greater benefit than other treatment options. Based upon the information set forth above, the requested device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 2

A 60-year-old male enrollee has requested authorization and coverage for verapamil. 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 penile traction therapy is a therapeutic option for men with Peyronies disease. Penile traction may help to preserve or increase penile length and reduce penile curvature when used as monotherapy or as adjuvant therapy for surgical and intralesional treatments. There is paucity of clinical justification regarding the efficacy of injection therapy with verapamil. Furthermore, addition of verapamil to oral therapy or other nonsurgical therapies does not appear to provide significant improvement. In sum, verapamil is not likely to be superior over other treatment options.
Summary Reviewer 1 
 
A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by 
FoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the enrollee's condition than any available standard therapy. The physician reviewer 
found that the National Comprehensive Cancer Network (NCCN) guidelines for the treatment of 
non-small cell lung cancer (NSCLC) note that there is growing recognition of the molecular 
mechanisms of resistance to therapy. Retesting a sample from a tumor that is actively progressing 
while exposed to targeted therapy can shed light on appropriate next therapeutic steps. Broad 
genomic profiling may be the most informative approach to examining potential mechanisms of 
resistance, which may require more than one instance of such profiling over the course of an 
individual patients therapy. While liquid biopsy should not be used in lieu of tissue-based testing, 
Rolfo  and  colleagues  note  that  isolation  and  analysis  of  circulating  cell-free  tumor 
deoxyribonucleic acid (DNA) in plasma is a powerful tool with considerable potential to improve 
clinical outcomes across multiple cancer types, including NSCLC. Cell-free tumor DNA testing 
generally has very high specificity. While it may also have significantly compromised sensitivity, 
with up to a 30% false-negative rate, current medical literature supports complementary testing to 
reduce turnaround time and increase the yield of targetable alteration detection. This is especially 
true with procedures that typically have a low yield of tissue such as endobronchial ultrasound 
(EBUS). Therefore, the service at issue was likely to have been more beneficial for treatment of 
the patients medical condition than standard therapy with tissue-based testing alone. Therefore, 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.
Summary Reviewer 3 
A 63-year-old female enrollee has requested reimbursement of liquid CDx laboratory testing by 
FoundationOne on 4/29/22. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the evaluation of the enrollees lung cancer. At issue is whether 
CDx laboratory testing by FoundationOne on 4/29/22 was likely to have been more beneficial for 
evaluation of the enrollee's condition than any available standard therapy. The physician reviewer 
found that Metastatic adenocarcinoma of the lung is an incurable disease, but many advances have 
been made with targeted therapies to help extend survival. Multiple guidelines including by the 
NCCN,  College  of  American  Pathologists  (CAP),  American  Society  of  Clinical  Oncology 
(ASCO), and European Society for Medical Oncology (ESMO), recommend testing for mutations 
such as epidermal growth factor receptor (EGFR), KRAS, anaplastic lymphoma kinase (ALK), 
and c-ros oncogene (ROS1) on tumor samples to help direct therapy options. If patients are not fit 
for biopsy, or if the tissue sample is insufficient for testing, then cell-free testing may help identify 
mutations.  Cell-free tests, such as the FoundationOne CDx liquid test at issue, are very specific 
but not as sensitive as tissue testing for mutations and are not a substitute when appropriate tissue 
can be obtained. In this case, notes dated 7/27/22 reported that the patient underwent a repeat 
biopsy on 4/12/22 by EBUS to confirm recurrent disease. Molecular testing and FoundationOne 
CDx liquid testing were requested from this sample at the same time. In this clinical setting, given 
that the tissue sample is considered more sensitive/specific than liquid biopsy and is the standard 
for diagnostic management, the service at issue was not likely to have been more beneficial than 
the standard management. Therefore, CDx laboratory testing by FoundationOne on 4/29/22 was 
not likely to have been more beneficial for evaluation of the patients condition than any available 
standard therapy.
Summary Reviewer 3


The parent of a 12-year-old male enrollee has requested authorization and coverage for Remicade 400 mg for two weeks and then once monthly for one year. The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees juvenile dermatomyositis (JDMS). The physician reviewer found the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, the patient has juvenile dermatomyositis which is moderate to severe and a biologic such as Remicade (infliximab) would likely be beneficial for this patient. Moreover, infliximab has been shown to be safe and effective in children with juvenile dermatomyositis. Riley and colleagues assessed the response of five refractory juvenile dermatomyositis patients to infliximab. The authors reported Improvements in all five patients as shown by positive changes in physician visual analogue scale (VAS), Childhood Myositis Assessment Score (CMAS), Childhood Health Assessment Questionnaire (CHAQ), joint range of movement and, in some, regression of calcinosis and skin signs. There were no major side effects observed with addition of infliximab to the therapeutic regime. For the reasons provided, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Summary Reviewer 1


A 48-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 1/26/16.  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 the current medical evidence supports the services at issue in this patients case.  According to 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, breast tomosynthesis performed on 1/26/16 was likely to have been of greater benefit than other methods of evaluation.  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.
Summary Reviewer 1

The patient is a 62-year-old male with a progressive group of symptoms consistent with a neurodegenerative disorder.  He has developed dysarthria, ataxia and possibly cognitive abnormalities of executive functioning. Per the records, magnetic resonance imaging (MRI) of the brain showed atrophy of the cerebellum, cerebellar peduncles, and pons and medulla consistent with multisystem atrophy or possibly spinocerebellar degeneration. The provider recommended dopamine transporter single photon emission computed tomography (DaT SPECT). The patient has requested reimbursement for DaT SPECT scan of the brain performed on 9/23/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  There is a lack of support for the services at issue in this clinical setting.  The differential diagnosis of spinocerebellar degeneration versus multiple system atrophy is established by clinical grounds. There is a lack of data demonstrating adequate sensitivity or specificity of DaT SPECT scanning in this clinical setting.  Therefore, DaT SPECT scan of the brain performed on 9/23/16 was not likely to have been more efficacious than 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.
Summary Reviewer 3


A 62-year-old female enrollee has requested reimbursement for Prolia injection performed on 8/27/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found the patient has a history of osteoporosis and multiple non-traumatic fractures.  The patient is at a high risk for a major osteoporotic fracture, and pharmacological therapy is recommended.  The medical evidence supports Prolia in this clinical setting.  This patient has been treated with Fosamax, with no benefit on the patients bone mineral density.  The medical notes indicate that the patients markers of bone turnover were elevated, indicating poor absorption or increased bone turnover from rheumatoid arthritis while on Fosamax therapy.  Thus, the Prolia injection provided on 8/27/15 was likely to have been more effective than other treatment options.  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.
Summary Reviewer 1


A 38-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/13/15.  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 there is sufficient support for the services at issue in this clinical setting.  According to 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 that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis performed on 7/13/15 was likely to have been of greater benefit than other methods of evaluating this patient.  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.