Persius/imr-appeals huggingface dataset:
Summary Reviewer 1

The parent of an 11-year-old female enrollee has requested reimbursement for the FirstStep PLUS test provided on 11/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees severe attention deficit hyperactivity disorder (ADHD) and developmental delays. The physician reviewer found that the clinical utility of CMA is well established, and is now considered first-line genetic tests for patients with developmental delays and autism spectrum disorders according to the American Academy of Pediatrics, the American College of Medical Genetics, the American College of Neurology and the Child Neurology Society (Schaefer, et al; Moeschler, et al; Shevell, et al; Shen, et al). In a study by Coulter and colleagues, a retrospective chart review of CMA testing was performed on patients with developmental delay, intellectual disability, autism spectrum disorders and congenital anomalies. Findings in this study demonstrated that CMA results influenced medical care by in the majority of patients by precipitating medical referrals, diagnostic imaging, or specific laboratory testing, supporting the use of CMA as a clinically useful diagnostic test. It is for these reasons, that the FirstStep PLUS test provided on 11/23/16 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 38-year-old male enrollee has requested reimbursement for the homocysteine testing provided on 9/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees anemia. The physician reviewer found that based on the records provided, the patient is a 38-year old male with unexplained anemia. Although elevated homocysteine levels have been associated with anemia, an elevated homocysteine level does not point to a specific cause of the anemia (den Elzen, et al). Moreover there is a lack of clinical trials that demonstrate outcome improvement with treatment targeted at reducing homocysteine levels (Lonn; Toole, et al). Likewise, even though results of homocysteine levels may be abnormal and considered independent risk markers for coronary disease, there is a paucity of scientific data demonstrating outcome benefits by treating routinely obtained abnormal results. Thus, the homocysteine testing provided on 9/5/14 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, I have determined 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 2 
A 68-year-old female insured has requested reimbursement for a Guardant360 CDx test provided 
on 1/19/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insured's metastatic non-small cell lung cancer. 
The physician reviewer found that the integration of next-generation sequencing (NGS) testing 
into the routine management of stage IV non-small cell lung cancer demonstrates a marked 
increase  in  the  detection  of  therapeutically  targetable  mutations  and  improved  delivery  of 
molecularly guided therapy. The National Comprehensive Cancer Network (NCCN) guidelines 
recommend liquid or plasma NGS if the patient has insufficient tissue from the tumor, or if 
expedited results are necessary. A repeat biopsy can delay care and lead to unnecessary procedures. 
In this case, the provider noted that the patient had insufficient tissue for full NGS testing. 
Therefore, the Guardant360 CDx test provided on 1/19/22 was likely to be more beneficial for the 
evaluation of the patients condition than any available standard therapy.
Summary Reviewer 

A 25-year-old transgender male enrollee has requested authorization and coverage for total hysterectomy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The Health Insurer noted that the requested services are not medically necessary because he needs to be living as male for two years and on hormones for one year before surgery. World Professional Association for Transgender Health (WPATH) has no requirements for social transition before hysterectomy. There is a one year requirement before reconstructive genital surgery, such as phalloplasty or metoidioplasty, but not for hysterectomy. Per WPATH, social transition is not required before hysterectomy. WPATH recommends one year of hormones before hysterectomy, unless this is not clinically indicated. The decision that this is clinically indicated before one year lies with the patients treatment team, which recommends the surgery. WPATH lists 12 continuous months of hormone therapy as appropriate to the patients gender goals (unless hormones are not clinically indicated for the individual). This provides flexibility for the treatment team to decide on the appropriate hormone treatment regimen before hysterectomy. WPATH noted that hysterectomy is one of the medically necessary treatments for gender dysphoria. There is sufficient support for the requested services in this clinical setting. Therefore, the requested hysterectomy is medically necessary for the treatment of this patient.
Summary Reviewer 

A 25-year-old female enrollee has requested authorization and coverage for surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that abnormal uterine bleeding is a common gynecologic problem. Prolonged uterine bleeding can result in anemia and interfere with daily activities, as in this case. Abnormal uterine bleeding encompasses a heterogeneous group of conditions with diverse etiologies. Diagnosing the etiology of the abnormal uterine bleeding involves a thorough history, physical examination, imaging, and endometrial sampling. This patient has undergone a thorough evaluation, with no distinct etiology found. Initial management usually consists of progestin-based treatments, including combination oral contraceptive pills, the 52 mg levonorgestrel-releasing intrauterine device, and tranexamic acid. Surgical treatment options include endometrial ablation for patients who desire uterine sparing or definitive treatment with hysterectomy for patient who have completed childbearing.  In this case, the patient has failed medical management options, including oral contraceptive pills and a short trial of Mirena intrauterine device, which she was unable to tolerate. She is not a candidate for tranexamic acid, given her prolonged bleeding pattern (greater than five days per month) and is not a candidate for endometrial ablation given her age and high risk of failure. The patient desires definitive management hysterectomy. Given that she has completed childbearing status-post bilateral salpingectomy, a hysterectomy is appropriate for this patient. Therefore, surgery to remove the uterus (laparoscopic or laparoscopic assisted vaginal hysterectomy) is medically necessary for the treatment of this patient.
Summary Reviewer 2

A 38-year-old male enrollee has requested reimbursement for genetic testing performed on 5/31/18. 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 molecular testing has emerged as a promising method for clarifying the gray area of indeterminate thyroid fine needle aspirations, with the aim of reducing the overtreatment of benign nodules and increasing the preoperative detection of malignant nodules that should be treated by a single surgery (total thyroidectomy) rather than a two-step procedure. When molecular testing informs patient management, it should be further integrated with clinical findings and ultrasonographic results. As additional information accumulates to further refine these integrated approaches to patient management, the genetic information provided by molecular tests is expected to increasingly individualize the management of patients with thyroid nodules and cancer. In this patients case, a second thyroid biopsy was not necessary because this test was done as a follow-up of an indeterminate result. A benign result by the ThyGenX/ThyraMIR test has a significant negative predictive value. The medical evidence supports the services at issue in this clinical setting. All told, genetic testing performed on 5/31/18 was likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 

The patient is a 42-year-old female who is requesting reimbursement for fetal chromosomal analysis via cell-free DNA. The records document advanced maternal age and history of prior miscarriages. The physician reviewer found that there is sufficient support for the services at issue in this clinical setting. Noninvasive prenatal screening by cell-free DNA is increasingly becoming accepted as an appropriate method for first trimester aneuploidy screening. Noninvasive prenatal screening is a sensitive screen for aneuploidy, is more sensitive than sequential screening, but does not require the invasive procedure of chorionic villus sampling or amniocentesis. This is the case for both younger women and for women of advanced maternal age. This test is less invasive, with less risk to the pregnancy. Therefore, fetal chromosomal microdeletions genomic sequence analysis (81422) performed on 7/09/19 was medically necessary for the evaluation of this patient.
Summary Reviewer 1

A 50-year-old female enrollee has requested authorization and coverage for minimally invasive sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the patient has chronic left sacroiliac dysfunction and pain that interferes with activities of daily living. The selected procedure of minimally invasive sacroiliac fusion using the triangular titanium implant is a relatively popular procedure, with 88 percent fusion rate and documented excellent results at five-year follow-up. Minimally invasive sacroiliac joint fusion has become an increasingly popular and accepted surgical option for chronic sacroiliac joint dysfunction, a common cause of unremitting chronic low back/buttock pain. Minimally invasive sacroiliac joint surgery has been proven to be a safe and effective procedure, with a high fusion rate, a good safety profile and significant improvements in pain severity and disability reported through 12 months post-procedure. A five-year follow-up showed continued excellent clinical responses in patients with sacroiliac joint pain treated with sacroiliac joint fusion using triangular titanium implants along with a high rate of joint fusion. Therefore, the requested minimally invasive sacroiliac joint fusion is likely to be more beneficial than any available standard therapy.
Summary Reviewer 


The parent of a 12-year-old male enrollee has requested authorization and coverage for Humatrope 12 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the requested medication is medically necessary for treatment of the patients medical condition. The patient has experienced a deceleration in growth velocity from the 40th percentile to fifth percentile between 2-11 years of age. IGF-1 level was low, and provocative GH testing results were poor. Based on auxological and biochemical criteria, the patient meets generally established guidelines for GH treatment. He had a good response to one year of therapy without adverse effects, and continuation of GH therapy is medically necessary until epiphyseal fusion. Withdrawal of therapy at the age of expected puberty may result in irreversible impairment in height potential. As such, Humatrope 12 mg cartridge has been established as medically necessary for treatment of the patients medical condition. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 


The parent of a seven-year-old male enrollee has requested authorization and coverage for Saizen 8.8 mg cartridge. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees growth hormone deficiency. The physician reviewer found the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patients height is not more than 2 SDS below the mean for age and gender, and his adult predicted height, based on the bone age and height assessment in March 2015, is approximately 66.5 inches, appropriate for his genetic potential. His growth factors are normal, he does not have any known morphological abnormalities of his pituitary gland, and there is no documentation of abnormal growth velocity for age. The delayed bone age is most consistent with a diagnosis of constitutional delay rather than GH deficiency. The patient underwent provocative testing with serial GH levels assayed for a period of three hours after the baseline measurement, but it is not clear from the results provided that two separate provocative tests were performed, with serial measurements of GH levels for 2-3 hours after each test independently. Although the U.S. Food and Drug Administration (FDA) has approved GH therapy for children with intrauterine growth retardation/small for gestational age with failure to catch-up in height, this patients height is not below the 3rd percentile on the growth curve, and thus he would not meet criteria for failure to catch- up in height. In addition, his adult height prediction is not short enough to qualify for GH on the basis of the FDA-approved idiopathic short stature indication. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 2


A 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 3/31/16.  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 This patient is a 62-year-old female who had a bilateral screening mammogram with tomosynthesis on 3/31/16. The patient reported a positive family history of breast cancer in her maternal grandmother, and in her maternal and paternal aunts. The patient presented for a breast screening examination on 3/31/16. The patients breast was noted with scattered fibroglandular densities in the right breast. The ultrasound showed small cysts. The Health Insurer has denied the tomosynthesis portion of the exam. The patient has appealed the denial and this denial is the subject of this appeal and determination.
The medical literature supports breast tomosynthesis in this clinical setting.  Per 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 state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 3/31/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service 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 62-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found the medical evidence supports the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Based upon the information set forth above, the service 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 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that this patient presented with chronic right wrist pain that interfered with his activities of daily living. He had a past medical history that included right distal radius fracture. Clinical examination findings were consistent with imaging evidence of right wrist post-traumatic arthritis of the radioscaphoid joint and STT joint with positive ulnar variance of 7.5 mm. He had failed to achieve sustained improvement with activity modification, medications, bracing and steroid injection. He underwent right wrist anterior and posterior interosseous neurectomies on 6/10/19 as an alternative to motion-limiting surgeries, including wrist fusion, proximal row carpectomy, and radioscapholunate arthrodesis. Current evidence-based medical literature supports the use of anterior and/or posterior interosseous neurectomies for the treatment of chronic wrist pain and to delay or avoid wrist fusion/reconstruction surgeries. There is adequate literature support for the use of this procedure as salvage prior to fusion. He had failed reasonable and/or comprehensive conservative treatment, and no additional conservative treatment would have been reasonably expected to improve his medical condition. Therefore, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Summary Reviewer 1


A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested services in this clinical setting.  The medical records document paroxysmal atrial fibrillation and a prior stroke with no documented significant bleeding complications on anticoagulation.  In this circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting an increased bleeding risk, discontinuing anticoagulation while accepting an increased thromboembolic risk or percutaneous left atrial appendage exclusion using a Watchman device.  The Watchman device has been demonstrated in one trial to be non-inferior compared with warfarin.  However, device placement has a high rate of significant complications due to pericardial effusion and procedural stroke related to thromboembolism or air embolization.  The Watchman device is not likely to be of greater benefit than other treatment options, especially in patients who are tolerating anticoagulation without significant bleeding side effects.  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 59-year-old male enrollee has requested authorization and coverage for spinal cord stimulator. The Health Insurer has denied this request and reported that the requested device is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the medical evidence supports the requested device in this clinical setting. Wong and colleagues concluded that the option of spinal cord stimulation should be considered after conservative therapy has failed. They pointed to large randomized control studies which showed that high frequency forms of stimulation was effective for chronic low back pain. A systematic review and meta-analysis by Taylor and colleagues concluded that spinal cord stimulation is an effective pain relieving treatment for chronic low back and leg pain with or without a prior history of back surgery.  The mean level of pain relief across 74 studies was found to be 58% at an average follow-up of 24 months. All told, the requested spinal cord stimulator is medically necessary for the treatment of this patient.
Summary Reviewer 1

A 38-year-old male enrollee has requested authorization and coverage for sirolimus cream. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. Tuberous sclerosis is a rare genetic disease, and there are not enough patients to have double blind, placebo-controlled studies for the treatment of the associated facial angiofibromas. Topical rapamycin or sirolimus is considered standard of care for the treatment of these lesions.  The International Tuberous Sclerosis Complex Consensus Statement also recommends the use of this medication for treatment of facial angiofibromas in tuberous sclerosis. Therefore, sirolimus cream is likely to be more beneficial than other available standard therapy.