Persius/imr-appeals huggingface dataset:
Summary Reviewer 

A 60-year-old female enrollee has requested authorization and coverage for Xifaxan 500 mg. 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 patient had small intestinal bacterial overgrowth. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication has been shown to have greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. Results are sustained for several weeks after treatment. Moraru and colleagues performed a prospective trial of patients with irritable bowel syndrome and small intestinal bacterial overgrowth. The authors found that 86% responded to Xifaxan, and symptoms were reduced as well. Xifaxan is effective for the treatment of constipation-predominant irritable bowel syndrome. In this case, while antispasmodic medications may address irritable bowel syndrome, they would not be expected to improve small intestinal bacterial overgrowth. Anti-diarrheal medications would not be appropriate in the use of constipation. Therefore, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients small intestinal bacterial overgrowth in the setting of irritable bowel syndrome.
Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement for DecisionDX-UM assay performed on 5/09/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ocular melanoma. The physician reviewer found that the DecisionDX is a study of 15 to 31 genes in a patients melanoma cells.  It has been used to classify the individuals melanoma as having either a high or low risk of metastasis.  It is controversial in cutaneous melanoma as to whether it has additional value when added to the usual pathologic prognostic factors.  However, it is particularly useful in the analysis of uveal melanoma and has been validated in several studies.  Specifically, a Class 1 category carries with it a less than 20% chance of metastasis, whereas Class 2 has a greater than 70% chance of metastasis.  This testing has become a standard in many ocular cancer centers.  Its clinical value lies in determining the need for intense surveillance, and possibly to assist in the decision as to adjuvant therapy.  Therefore, DecisionDX-UM assay performed on 5/09/16 was likely to have been superior over 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.
Summary Reviewer 1

A 67-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees bilateral sacroiliac joint pain status post revision lumbar surgery. The physician reviewer found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the criteria for sacroiliac joint fusion have not been met in this patients case. The patients records do not include documentation of failure to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest; physical therapy; or sacroiliac joint steroid injection must be reported. Moreover, there must be evidence that additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Thus, although the patient has demonstrated continued pain that interferes with activities of daily living and results in functional disability, the patient has not adequately satisfied all of the ISASS criteria. All told, the requested sacroiliac joint fusion 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 service 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.
Summary Reviewer 1

A 52-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 enrollees medical condition. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in the cells of an individuals melanoma. It then classifies the melanoma based on the five-year risk of metastases. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients having sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the clinical value of the assay. It is not known how the five-year DecisionDx-Melanoma data compares and relates to the 10-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma class can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 

The patient is a 42-year-old female who has been treated for the following conditions: low back pain; other intervertebral disc degeneration, lumbosacral region; other intervertebral disc degeneration, lumbar region; radiculopathy, lumbar; other spondylosis, lumbar region; other intervertebral disc displacement, lumbar region. The patient has requested authorization and coverage for spinal surgery. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.  The physician reviewer found that Bydon and colleagues noted, aA trial of conservative therapy may be considered for patients with low-grade spondylolisthesis presenting with radiculopathy and/or pseudoclaudication. These options may include physical therapy, epidural steroid injection, and pain medications. If unresolved, surgical options may include decompression alone or decompression and fusion.a Chan and colleagues stated, aPatients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate.a  In this patientas case, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to requested surgery to include (but not limited to) physical therapy measures. In addition, she is noted to be a daily tobacco user and notes she will quit nicotine; however, follow-up documentation does not indicate this has been completed. The provided imaging studies, including the dynamic x-rays from 8/10/21, do not corroborate movement/instability at the requested level, and detailed documentation is not evident regarding potential impending/inevitable temporary intraoperative instability. There is a lack of support for the requested services in this clinical setting. Therefore, the requested spinal surgery is not medically necessary for the treatment of this patient.
Summary Reviewer 2



A 36-year-old female enrollee has requested reimbursement for infliximab antibody testing performed on 3/30/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that management of ulcerative colitis using infliximab antibody testing has not been standardized, and recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed (Kornbluth, et al). In addition, the use of infliximab antibody testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established (Steenholdt, et al). Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response (Vande Casteele, et al; Nanda, et al). A recent study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies (Adedokun, et al). Based on the clinical literature, the infliximab antibody testing performed on 3/30/15 was 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 


A 53-year-old male enrollee has requested reimbursement for inpatient hospital stay from 12/20/16 through 12/24/16.  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 the submitted documentation supports the medical necessity of a portion of the services at issue.  Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition with new onset atrial fibrillation and could have been treated at a lower level of care. At the time of admission, the patient was afebrile with a normal white blood cell count and was hemodynamically stable without evidence of congestive heart failure.  On 12/22/16, the patient was noted to have worsening abdominal pain with a worsening leukocytosis and imaging consistent with acute cholecystitis.  Given the patients recent arrhythmia and need for anticoagulation, the patient was at high risk for perioperative complications. Therefore, a cholecystostomy catheter was placed for drainage. In this case, the patients clinical course worsened.  Given the potential for cardiac complications, acute inpatient medical admission from 12/22/16 through 12/24/16 was medically necessary. However, inpatient hospital stay from 12/20/16 through 12/21/16 was not medically necessary for the treatment of this patient. 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.
Summary Reviewer 3
A 32-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 4/12/21. 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 polymerase chain reaction testing has been compared to traditional testing for vaginitis. The literature supports the use of polymerase chain reaction testing because it results in significantly higher sensitivity and negative predictive value than clinical diagnosis or clinical testing.  The test was also superior for detecting more than one cause for vaginitis. The medical evidence supports polymerase chain reaction testing as a means of accurate detection which allows for appropriate treatment. Therefore, polymerase chain reaction testing performed on 4/12/21 was likely to have been more beneficial for evaluation of the patientas condition than any available standard therapy.
Summary Reviewer 2

A 61-year-old male enrollee has requested reimbursement for surgical services (atrial fibrillation ablation) performed on 7/10/13. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees recurrent symptomatic atrial fibrillation. The physician reviewer found the surgical services performed on 7/10/13 were 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 presented with symptomatic paroxysmal atrial fibrillation in spite of a prior remote ablation in 2011 and suppressive antiarrhythmic medication trials. Since the patient continued to have significant symptoms in spite of attempts at rate control and rhythm control a second atrial fibrillation ablation procedure in this clinical setting was reasonable and medically appropriate and considered the standard of care in the medical community. The highest success in preventing atrial fibrillation with ablation is in those patients with paroxysmal (as opposed to persistent) atrial fibrillation (January, et al). Also, cryoablation has favorable results compared to radiofrequency ablation (Packer, et al). Given that the repeat ablation procedure performed on 7/10/13 was clinically indicated to relieve symptoms and is the standard of care in the medical community, the surgical 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.
Summary Reviewer 1 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that Temporomandibular joint disorders 
usually present with symptoms and signs such as pain, mandibular movement, dysfunction, or 
joint sounds. Bruxism is characterized by teeth grinding. Botulinum toxin A (Botox) is a biologic 
toxin which inhibits skeletal muscle through hindering the production of acetylcholine in the 
nerve endings. The use of Botox for treatment of temporomandibular joint disorders and bruxism 
is not consistent with U.S. Food and Drug Administration (FDA) indications. While there are 
reports of the clinical use of Botox for the treatment of temporomandibular joint disorders and 
bruxism, the clinical evidence in current medical literature is insufficient to demonstrate the 
clinical efficacy of Botox in the treatment of temporomandibular joint disorders and bruxism or 
that it is more beneficial than standard therapies including the use of occlusal devices, NSAIDs, 
and physical therapy. Therefore, Botox is not likely to be more beneficial for treatment of the 
patients condition than any available standard therapy.
Summary Reviewer 

A 64-year-old male enrollee has requested reimbursement for inpatient stay at telemetry level of care provided from 5/23/18 through 5/30/18. 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 at the time of admission, the patient had a low potassium and an elevated troponin level. He had multiple cardiac risk factors, including hypertension, diabetes mellitus, congestive heart failure and advanced renal disease. Given these risk factors and the severity of his infection and wounds, it was reasonable to admit him to a telemetry level of care for 24 hours. The initial 24 hours is sufficient time to check serial echocardiogram and cardiac enzymes and have a cardiology consultation. Furthermore, the potassium level was improved by 5/24/18. He did not have any chest pain or acute ischemia on admission, and after monitoring and serial enzymes/echocardiograms, he could have been treated at a lower level of care from 5/25/18 through 5/30/18. Therefore, inpatient stay at telemetry level of care provided from 5/23/18 through 5/24/18 was medically necessary for the treatment of this patient. The records fail to demonstrate the medical necessity of inpatient stay at telemetry level of care provided from 5/25/18 through 5/30/18.
Summary Reviewer 3

The patient is a 56-year-old male who sustained a ventricular fibrillation related cardiac arrest in the setting of an acute anterior ST-elevation myocardial infarction. The patient was hospitalized from 7/31/16 through 8/05/16.  He was successfully resuscitated and treated with drug eluting stent to the left anterior descending artery. Following the procedure, additional episodes of ventricular fibrillation were documented, and he was treated with cardioversion and amiodarone. Thrombus was noted at the site of the recent left anterior descending artery stent placement which was treated with angioplasty, and critical right coronary artery lesion was subjected to percutaneous coronary intervention/stenting. The ejection fraction following the procedure was 47%. The patient has requested reimbursement for wearable cardioverter defibrillator. The Health Insurer has denied this request and reported that the device at issue was investigational for the treatment of this patient.  The medical evidence has not demonstrated the superior efficacy of the device at issue in this patients case. There is a lack of support for an improvement of health outcomes when a wearable cardioverter defibrillator is deployed in this clinical setting. Implantable cardioverter defibrillator placement can be undertaken 90 days after a percutaneous coronary intervention/stenting procedure if the ejection fraction remains below 35 percent or 40 days after a myocardial infarction if there is no intervention and the ejection fraction remains below 35 percent.  There is lack of support for the device at issue in this case. Thus, the wearable cardioverter defibrillator was not likely to have been more effective than other treatment modalities. 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.
Summary Reviewer 2

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that in this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The U.S. Food and Drug Administration (FDA) has approved the Watchman device. The Watchman device is an appropriate alternative in patients who are deemed to be at prohibitively high bleeding risk while on long-term anticoagulation, such as is documented with this patient. The requested services are likely to be more beneficial than the alternative of long-term anticoagulation in this patient with a documented high risk of recurrent bleeding. In sum, the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) is likely to be more efficacious than other available treatment options. 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 3

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that the Watchman device is an effective and relatively safe option for patients with atrial fibrillation who require but cannot take long-term anticoagulation. However, this patient underwent successful atrial fibrillation ablation with no documented recurrence of atrial fibrillation when the device had been regularly interrogated. Therefore, long-term anticoagulation would not be indicated to justify the need for a Watchman device. Thus, the superior efficacy of the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) has not been demonstrated. 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 3

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma test is an attempt to determine risk of recurrence for early stage melanoma. However, the treatment protocol for follow up of melanoma patients is summarized in the National Comprehensive Cancer Network (NCCN) guidelines. These guidelines note there is a lack of data to support using adjuvant therapy based on DecisionDx testing results. The follow up of melanoma patients is not tailored to each patient risk of recurrence, but rather is global to all patients with melanoma. Given these findings, the DecisionDx testing performed on 4/28/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.