Persius/imr-appeals huggingface dataset:
Summary Reviewer 3

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 breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  However, in this case, the patients presenting symptom was breast pain.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In addition, her breast density was described as containing scattered areas of fibroglandular elements.  Her breasts were not particularly dense.  Breast tomosynthesis has not been shown to provide significant increased value in this clinical setting.  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 

A 64-year-old female enrollee has requested reimbursement for repair of cartilage in the left ankle joint performed on 11/14/18. 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 Osteochondral lesions of the talus occur in up to 70% of acute ankle sprains and fractures. These lesions have become increasingly recognized with the advancements in magnetic resonance imaging (MRI) scans. A fair number of these lesions can remain symptomatic and necessitate surgery. In this case, the lesion had remained symptomatic for over two years before the second surgery. Thus, additional surgery was needed. The type of surgery has included either reparative procedures, such as bone marrow stimulation, or replacement procedures, such as autologous osteochondral transplantation. Reparative procedures are generally indicated for smaller lesions, such as this one. The reparative techniques include debridement and bone marrow stimulation techniques, such as microdrilling and microfracture. Regenerative techniques include autologous osteochondral transplants utilized for larger lesions. A review of the current literature indicates drilling, microfracture and insertion of micronized cartilage and bone marrow aspirate concentrate appears to be a safe and effective treatment option for osteochondral lesions of the talus. The addition of bone marrow aspirate concentrate and micronized cartilage does not result in an increase in ankle or donor site morbidity. It is a well-tolerated therapy that significantly promotes healing and decreases revision rates for treatment of the osteochondral lesions when compared to debridement and microfracture alone. Therefore, repair of cartilage in the left ankle joint performed on 11/14/18 was medically necessary for the treatment of this patient.
Summary Reviewer 1

A 39-year-old male enrollee has requested reimbursement for Anser IFX testing provided on 4/23/14. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The medical evidence has not established whether therapy guided by following trough drug levels and drug antibodies is superior to routine good clinical care.  The data available are uncontrolled and come from retrospective analyses.  In general, for a patient failing therapy, there is a trend toward lower trough drug levels with or without the presence of antibody.  However, many patients fail therapy with a normal drug level for a variety of reasons.  All told, Anser IFX testing performed on 4/23/14 was not likely to have been more effective than other methods of evaluation.  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 1

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. 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 clinical utility of chromosomal microarray (CMA) is well-established, and is now considered first-line genetic testing for individuals with developmental delays and autism spectrum disorders. It is important to note that CMA technology has been shown to provide clinically actionable information. Research continues to support the use of CMA testing in the evaluation of developmental delays and autism spectrum disorders. Recent evidence-based international guidelines promote the use of CMA as a first-tier investigation for global developmental delay if no etiological indicators from history and examination are found. The higher sensitivity that it has for identifying submicroscopic deletions and duplications (than standard karyotyping methods) and better definition of the breakpoints and size of imbalances all make CMA a suitable first-line test. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.
Summary Reviewer 


A 20-year-old male enrollee has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation therapy from 6/30/16 forward.  The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Documents critical to the review, such as a psychiatric assessment, interpretative summary, serial progress notes, longitudinal history of the illness burden and outcomes of specific evidence-based psychotherapies and non-pharmacologic interventions, were not presented.  The information provided, including the patients lengthy course of treatment with mood stabilizing and antipsychotic medications and poor tolerability of antidepressants, strongly suggests bipolar depression rather than a unilateral mood disorder and does not detail the influence of the patients psychiatric comorbid conditions.  Considering transcranial magnetic stimulation is indicated for the acute phase treatment of major depressive disorder at this time, and the safety and effectiveness of transcranial magnetic stimulation therapy has not been established for other psychiatric disorders, the medical necessity of the services at issue cannot be established.  All told, transcranial magnetic stimulation therapy from 6/30/16 forward was not and is not medically indicated for the treatment of this patient.  Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Summary Reviewer 2

A 64-year-old female has requested reimbursement for DecisionDx-Melanoma assay provided on 3/21/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. 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 the DecisionDx-Melanoma assay has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. In sum, DecisionDx-Melanoma assay provided on 3/21/18 was not 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 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 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee, who has been diagnosed with inflammatory bowel disease, psoriasis and juvenile ankylosing spondylitis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting. Cimzia is an anti-tumor necrosis factor medication which is indicated for the treatment of psoriasis, inflammatory bowel disease and ankylosing spondylitis/sacroiliitis. These diseases are the same in children and adults and respond to therapy similarly. Currently, there is an active trial being conducted, the Pediatric Arthritis Study of Certolizumab Pegol (PASCAL). This is a phase 3, multicenter, open-label study to assess the pharmacokinetics, safety, and efficacy of certolizumab pegol (Cimzia) in children and adolescents with moderately to severely active polyarticular-course juvenile idiopathic arthritis. In this patients case, Cimzia is a medically appropriate treatment option. Thus, Cimzia loading dose 400 mg (two injections), then 200 mg subcutaneous every two weeks, three applications are medically necessary for the treatment of this patient. Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Summary Reviewer 2

An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. 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 there is sufficient support for the requested services in this clinical setting. This patient has already failed CPAP therapy and is not an optimal candidate for oral appliance therapy due to the severity of his obstructive sleep apnea. Multiple studies have demonstrated that hypoglossal nerve stimulation or Inspire airway stimulation improves health for people with obstructive sleep apnea with clinically significant decreases in observed mean apnea-hypopnea index and improvements in quality of life. The American Academy of Otolaryngology-Head and Neck Surgery considers aupper airway stimulation via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be a safe and effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy.a All told, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.
Summary Reviewer 3

A 45-year-old female enrollee has requested authorization and coverage for autologous chondrocyte implantation of the knee. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees knee pain. The physician reviewer found that surgical implantation of healthy cartilage cells (autologous chondrocyte implantation) is an alternative option for the treatment of large articular cartilage defects. Autologous chondrocyte implantation is primarily used to treat full-thickness cartilaginous defects of the distal femur by arthroscopically extracting healthy chondrocyte cells from the patients knee, culturing the cells, and implanting them back into an articular defect via an open surgical procedure. In general, autologous chondrocyte implantation is recommended as a second-line surgical option either after failure of initial arthroscopic repair or when a full-thickness articular cartilage defect is very large (2.5 cm2 or greater).  Autologous chondrocyte implantation should also be avoided in obese patients who have been shown to have no sustained improvement at two years. Worse outcomes have been reported in females with autologous chondrocyte implantation, especially in patients with patellar defects. Weak evidence has suggested some success with patellar autologous chondrocyte implantation, which remains off-label, but quality randomized controlled trials are lacking. In this patients case, the records noted a bipolar chondral lesion of the patellofemoral joint, which is a contraindication for autologous chondrocyte implantation. The failure rate of this procedure is high in this location. Thus, autologous chondrocyte implantation of the knee is not likely to be more efficacious than other treatment options. 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 1

A 21-year-old female enrollee has requested authorization and coverage for Octagam infusions. 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 the treatment of autonomic neuropathy can often involve multidisciplinary strategies, both from cardiovascular medicine as well as neurology. This patient has been treated with a variety of modalities, including beta-blocker therapy, fludrocortisone and pyridostigmine, but has some persistent symptomatology. There is the additional factor that there may be comorbidities to suggest autoimmune disorder as well. However, the use of intravenous immunoglobulin to treat autonomic dysfunction remains investigational. The study by Schofield is retrospective and only included 38 patients. There is a lack of support for the requested medication in this clinical setting. Therefore, Octagam infusions are not likely to be more beneficial than any available standard therapy.
Summary Reviewer 1

A 47-year-old female enrollee has requested reimbursement and prospective authorization and coverage for pertuzumab injections from 8/18/15 forward. The Health Insurer has denied this request indicating that the services at issue were and are considered investigational for treatment of the enrollees medical condition. The physician reviewer found pertuzumab is a monoclonal antibody that targets HER2 positive breast cancer cells, similar to, but not exactly in the same way as trastuzumab.  In metastatic breast cancer, when used in combination with chemotherapy and trastuzumab, pertuzumab yields superior progression-free survival compared to treatment with Taxotere-Herceptin without pertuzumab.  Combining pertuzumab with Herceptin and chemotherapy also appears to be superior to the combination without pertuzumab in the neoadjuvant situation.  However, there is a lack of data to support the use of combining pertuzumab with trastuzumab in the adjuvant setting.  Therefore, the superior efficacy of pertuzumab injections from 8/18/15 forward 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 51-year-old female enrollee has requested authorization and coverage for the LINX reflux management system lower esophageal sphincter augmentation. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees gastroesophageal reflux disease (GERD). The physician reviewer found that overall, there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another best-evidence review concluded that long-term comparative outcome data past one year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). Further, the American College of Gastroenterology (ACG) guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, the requested LINX reflux management system lower esophageal sphincter augmentation 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  
The patient is a 60-year-old female with a history of class 1 obesity complicated by dyslipidemia. The 
records available for review indicate that the patient had a body mass index (BMI) over 30 kg/m2 prior 
to beginning treatment with Wegovy. The physician reviewer found that the issue is whether the 
requested Wegovy solution auto-injector 0.25 mg/0.5 mL is medically necessary for the treatment of 
this patient. According to Gadde and colleagues, while lifestyle modification is recommended as the 
cornerstone of obesity management, many patients do not achieve long-lasting benefits due to difficulty 
with adherence as well as physiological and neurohormonal adaptation of the body in response to 
weight loss. There are multiple pharmacologic therapies available for weight management. Wegovy is a 
member of a class of medications known as glucagon-like peptide 1 (GLP-1) analogs. As noted in the 
medical literature, GLP-1 analogs have been shown to improve glycemic control, reduce body weight, 
and decrease cardiovascular risk (Knudsen and Lau). Studies have demonstrated Wegovys ability to 
promote weight loss via reduced appetite and energy intake and delayed gastric emptying (Cornell). In 
this case, the patient has a history of class 1 obesity complicated by dyslipidemia. The records reflect 
that the patient has attempted treatment with diet management and exercise without significant 
benefit. Per the provider, the patient has contraindications or intolerances to several weight loss 
medications. Wegovy has been shown to effectively promote weight loss for patients in conjunction 
with diet and exercise. Furthermore, the patient has demonstrated prior weight loss success with 
Wegovy. All told, the requested Wegovy solution auto-injector 0.25 mg/0.5 mL is medically necessary 
for the treatment of this patient.
Summary Reviewer  
The patient is a 52-year-old female who presented to her provider on 3/17/22. The patient reported 
pain in her left knee that she rated at an eight out of a scale of ten. The patient has requested 
reimbursement for Synvisc from 6/15/22 through 6/29/22. The Health Insurer has denied this 
request and reported that the services at issue were not medically necessary. This denial is the 
subject  of  this  appeal  and  determination.  The  physician  reviewer  found  that  the  submitted 
documentation supports the medical necessity of the services at issue. Per the medical literature, 
although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is 
not known as to which individuals will benefit. The current evidence is limited, and guidelines 
from organizations such as the American Academy of Orthopedic Surgeons indicate that the 
evidence  is  not  conclusive.  In  light  of  the  foregoing,  viscosupplementation  can  only  be 
recommended in individuals with a history of lasting benefit from prior injections, and in carefully 
selected cases where everything else has been tried, and the options are limited. In this case, the 
patient reported pain at a level of eight out of ten that did not respond to a corticosteroid injection 
on 3/17/22. The patient had tried and failed other conservative treatments. Given the patients 
limited options and based on the current medical literature, the services at issue were medically 
indicated. Therefore, Synvisc from 6/15/22 through 6/29/22 was medically necessary for the 
treatment of this patient.
Summary Reviewer 1 
 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The physician reviewer found that American Institute of Ultrasound Medicine (AIUM) notes that 
detailed obstetric ultrasound examination is not intended to be the routine ultrasound examination 
performed for all pregnancies. Rather, the AIUM notes that it is an indication-driven examination 
performed for a known or suspected fetal anatomic abnormality, known fetal growth disorder, 
genetic abnormality, or increased risk for a fetal anatomic or genetic abnormality or placenta 
accreta spectrum. The Society for Maternal-Fetal Medicine (SMFM) notes that the performance 
of the detailed fetal anatomic examination should be rare outside referral practices with special 
expertise in the identification and diagnosis of fetal anomalies. In this case, notes dated 6/2/22 
reported a body mass index of 28 kg/m2, the demise of a dichorionic twin at seven weeks, and the 
finding of a uterine synechia. However, these are not indications that the more detailed fetal 
ultrasound  at  issue  was  likely  to  be  beneficial  than  standard,  routine  ultrasound  screening 
Therefore, ultrasound and reading of the ultrasound on 8/2/22 was not likely to have been more 
beneficial for evaluation of the patients condition than any available standard therapy.