Persius/imr-appeals huggingface dataset:
Summary Reviewer 2

The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found in general, diminished or suboptimal response to infliximab or adalimumab can be managed in several ways such as shortening the interval between doses, increasing the dose, switching to a different anti-TNF agent or switching to a non-anti-TNF agent based on clinical observation in lieu of Anser IFX testing. In this patients case, the medical records submitted for review do not support acute loss of therapeutic response nor acute disease flare. There are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. In addition, the clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. In sum, the testing at issue was not clinically indicated and 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.
Summary Reviewer 3


A 43-year-old female enrollee has requested reimbursement for molecular pathology testing provided on 4/14/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer. The physician reviewer found the molecular pathology testing provided on 4/14/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers (Brose, et al; Thompson and Easton). BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers (Liede, et al; Tai, et al; Ferrone, et al). In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. Notably, the Amsterdam criteria have low sensitivity in HNPCC detection so the Bethesda guidelines were developed (Umar, et al). However, these guidelines are highly focused on patients with colorectal cancer who have microsatellite instability although the occurrence of microsatellite instability in other Lynch syndrome associated tumors was discussed. The most common extracolonic tumors in Lynch syndrome are endometrial, ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral cancers. This patients family history is suggestive of a breast/ovarian cancer syndrome. The MyRisk panel is appropriate since the current clinical situation may be caused by several potential cancer-causing genes. Therefore, the testing at issue 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.
Summary Reviewer 1


A 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found that on the information provided, it appears that the TMS is being used for maintenance or continuation purposes, which is consistent with an investigational application.  A typical course of TMS consists of 30 to 40 sessions spanning four to six weeks.  For patients who respond well to TMS, clinical improvement is usually maintained with psychotherapy and psychotropic medication.  Although small studies are demonstrating good tolerability and clinical efficacy of TMS therapy for treatment courses lasting years at a time, according to the summary of TMS treatment recommendations authored by Perera and colleagues, The standard parameter setprovided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established.  In other words, at this time there is a lack of well-designed and adequately-powered controlled studies showing the benefit of longer courses of TMS therapy.  Therefore, the superior efficacy of maintenance TMS therapy as compared to other available standard therapy, such as ongoing pharmacotherapy, psychotherapy and electroconvulsive therapy, has not been established.  Based upon the information set forth above, the services at issue were not and 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 35-year-old female has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 9/15/16 through 4/17/17.  The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees major depressive disorder. The physician reviewer found this patient received 36 treatments prior to the Health Insurers denial.  At this time, the literature on TMS is not clear on whether maintenance treatment is an evidence-based treatment.  The literature indicates that continued treatment can and should occur if an initial response to TMS is not apparent.  However, in this case, the patient did show an initial response to TMS treatment.   The records indicate that the patients symptoms had improved during the initial TMS treatment period.  Since the patient showed benefit from acute/initial TMS treatments and given the lack of evidence for maintenance TMS treatments, the superior effectiveness of the services at issue has not been established.  Based upon the information set forth above, the services at issue were not and 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 2


A 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that Enbrel is appropriate for this patients diagnosis of ankylosing spondylitis. However, if the patient does have systematic lupus erythematosus, than it is not suggested to use Enbrel or other anti-tumor necrosis factor (TNF) agents as these drugs can trigger lupus. Given the presentation in the records, the patient does not have systematic lupus erythematosus, rather she carries a low titer double stranded deoxyribonucleic acid (dsdna) antibody which is being monitored. Thus, the requested Enbrel is 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 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 54-year-old female enrollee has requested reimbursement for the shingles vaccine performed on 2/06/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of rheumatoid arthritis. The physician reviewer found the varicella-zoster virus causes two clinically distinct forms of infection.  Herpes zoster is related to reactivation of varicella-zoster virus infection and is characterized by a painful, unilateral vesicular eruption in a dermatomal distribution. The herpes zoster vaccination can decrease the risk of developing herpes zoster and post-herpetic neuralgia associated with infection.  The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all patients 60 years of age or older, including patients who report a previous episode of zoster and patients with chronic medical conditions (such as chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease), unless those conditions are contraindications. In clinical practice, the vaccine is recommended for patients between 50 and 59 who are receiving low-level immunosuppressive therapy or are expected to receive high-level immunosuppressive therapy or for patients that would have difficulty tolerating a zoster infection. In this case, the patient has multiple skin conditions including lichen planus, herpes simplex virus, and atopy, and she has been diagnosed with rheumatoid arthritis. Rheumatoid arthritis is treated with immunosuppressive medications that would leave the patient vulnerable to infections. Given this patients rheumatoid arthritis and skin conditions, it was appropriate to vaccinate this patient. Therefore, the shingles vaccine performed on 2/06/17 was likely to have been of greater benefit 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 2

A 22-year-old male enrollee has requested reimbursement for (81229) cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities on 3/16/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that there is a lack of evidence based literature that show the efficacy of genetic testing in evaluating patients  diagnosed with bipolar disorders or ADHD. There is very limited clinical justification, based on substantial medical research, to endorse genetic screening tests prior to attempting another medication for treatment of ADHD, bipolar disorder, or personality disorders.  Specifically, the standard of care for treatment of these disorders would be to continue to trial or prescribe stimulant medication. This method of prescribing medication would produce similar outcomes when compared to awaiting genetic testing results in this patients case.  In sum, cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and SNP variants for chromosomal abnormalities administered on 3/16/16 were not likely to have been more effective than the standard options available for the evaluation of this patient. Therefore, for the reasons stated above, the services at issue were not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Summary Reviewer 

The patient is a 28-year-old female with a history of severe persistent eosinophilic asthma. She has requested authorization and coverage for Fasenra Pen. The physician reviewer found that Benralizumab (Fasenra) is a cytotoxic monoclonal antibody directed against IL-5 receptor alpha that is approved by the U.S. Food and Drug Administration (FDA) as add-on therapy in patients with severe asthma and an eosinophilic phenotype. The submitted documentation indicates that the patient has severe persistent asthma and has required several courses of oral steroids for uncontrolled asthma symptoms. The patient has been using Symbicort and Breztri, and she continues to have episodes of asthma flare-ups. Her blood eosinophil count in end of August 2021 was greater than 150 cell/ml. The provider attested that she will continue to use inhaled corticosteroids Symbicort in conjunction with Fasenra therapy. There is sufficient support for the requested medication in this clinical setting. Therefore, the requested Fasenra Pen is medically necessary for the treatment of this patient.
Summary Reviewer 


A 25-year-old male enrollee has requested reimbursement for substance abuse residential treatment services provided from 7/22/17 through 8/3/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance and alcohol abuse. The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He had no comorbid medical conditions and he was psychiatrically stable. His medications could have been managed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and working the program. He was cooperative and participating in his treatment plan. Although the patient continued to require further treatment to develop and solidify coping skills, this did not require the residential structure. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. Thus, as of 7/22/17, the patient no longer met the criteria for residential level of care. Accordingly, the substance abuse residential treatment services provided from 7/22/17 through 8/3/17 were not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 1


A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The medical literature suggests that continued research is still necessary to develop clear guidelines for the usage of pharmacogenetics testing. Therefore, pharmacogenetics testing is not considered the standard treatment. However, in this case, the patient has already been treated with eight different antidepressants, with at least three different pharmacodynamic strategies, and has not had a good response. Given that she has failed the standard treatments that are available, the pharmacogenetics testing was medically reasonable in this clinical setting. The genetic testing has the potential to guide the providers decisions to medications that will be better tolerated and more effective. Therefore, the gene testing performed on 8/11/16 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.
Summary Reviewer 3


A 32-year-old female enrollee has requested reimbursement for the gene testing performed on 8/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees behavioral health condition. The physician reviewer found that despite its promise, pharmacogenetics is not yet ready for mainstream clinical application. The American Psychiatric Association (APA) does not endorse such testing in its current clinical practice guidelines. In this case, the documentation submitted for review failed to show the patients longitudinal illness burden and extent of impairment at the time of testing, including family history, psychosocial stressors, substance use disorders and medical comorbidities. In addition, there was no mention of prior interventions used to treat panic, depression and excessive worry. Without the review of the specific type, setting and duration of psychotherapies, or, the selection, dosing and length of previous psychotropic medication trials, it cannot be inferred that the patient had exhausted standard treatments available to treat her condition. In sum, considering the relevant peer-reviewed literature and current practice standards, it is not possible to assert with any degree of confidence that the disputed gene test yielded information that significantly influenced treatment decisions, improved the patients condition, prevented a more serious episode of illness or reduced morbidity. Thus, the gene testing performed on 8/11/16 was not likely to be more beneficial for treatment of the enrollees 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 3

The patient is a 20-year-old male with significant daytime frequency every hour and nocturia every four to six hours. The patient reportedly also has insomnia. The patient has tried pelvic floor muscle rehabilitation as well as multiple medications including oxybutynin, Vesicare, and Myrbetriq. The patient experienced side effects and no substantial improvement in his symptoms with these therapies. The patient is currently on desmopressin with some improvement. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. It was suggested that this patient undergo treatment with PTNS therapy for significant urinary frequency. The records document treatment failure with multimodal primary and secondary treatments for his condition. He does not wish to proceed with sacral neuromodulation or Botox injections. As noted in the medical literature, PTNS is performed as a salvage procedure. For these reasons, the PTNS provided on 10/16/17 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 service at issue was 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 66-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/17/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. There are two important decision points in the treatment of cutaneous melanoma. The first is
whether or not to do sentinel node; the pathology alone here strongly indicates that the procedure should be done. The second issue is that of whether adjuvant therapy should be given. Coupling the initial pathology, along with the results of the sentinel node, would give enough information to make the decision about adjuvant therapy.
DecisionDx-Melanoma testing is a study of 31 genes in an individualas melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami reported on 217 cases and found good correlation between DecisionDx-Melanoma testing prediction and prognosis in patients undergoing sentinel node biopsy. However, it is not clear how the DecisionDx-Melanoma testing five-year data compares to the ten-year Balch data. Most importantly, it is not known if it can be used to make therapeutic decisions beyond those that can be made on the pathologic data. Therefore, DecisionDx-Melanoma testing performed on 5/17/19 was not likely to have been more beneficial than other available standard therapy.
Summary Reviewer 1


A 60-year-old male enrollee has requested reimbursement for the fecal calprotectin testing performed on 11/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees Crohns disease.   The physician reviewer found calprotectin is a small calcium-binding protein and is a member of the S100 family of zinc-binding proteins found primarily in neutrophils. Any disturbance to the mucosal architecture due to the inflammatory process, results in leakage of neutrophils, and hence, calprotectin, into the lumen and its subsequent excretion in feces. Studies have demonstrated that of patients with Crohns in remission, only a small percentage had a significant within-individual variability for calprotectin concentrations over three samples suggesting that measurements are reliable (Walsham and Sherwood; Schoepfer, et al; Sipponen, et al). Given this support, the fecal calprotectin testing performed on 11/17/15 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.