Persius/imr-appeals huggingface dataset:
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
A 50-year-old female enrollee has requested authorization and coverage for Balversa 4 mg 
tablets (two tablets per day). The Health Insurer has denied this request indicating that the 
requested medication is considered investigational for treatment of the insureds urothelial 
carcinoma. The physician reviewer found that as noted in the medical records, this patient 
presents with metastatic lung cancer with metastases to brain, liver, and bone. The patient has 
been treated with Tagrisso plus Balversa therapy with improvement of her condition. The 
provider has recommended continuation of this therapeutic regimen. As noted in the medical 
literature, patients with EGFR mutations with initial responses to osimertinib have been able to 
overcome resistance with the addition of Balversa both in vitro and in small case reports. This 
patient  is  not  listed  as  having  positive  PDL1  or  other  markers  to  indicate  benefit  from 
immunotherapy. The patient was noted to have pneumonitis increasing the risk of recurrence 
with immunotherapy. There are limited options for treatment after recurrence on osimertinib. 
Given this support, the requested Balversa 4 mg tablets (two tablets per day) is likely to be more 
beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2
A 56-year-old male enrollee has requested reimbursement for FoundationOne testing performed on 3/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees recurrent myxofibrosarcoma.  The physician reviewer found that this documentation provided supports the efficacy of the services at issue in this clinical setting. Myxofibrosarcoma is a rare cancer that is found to have a very heterogeneous genetic make up. Treatment is difficult due to rarity and lack of established guidelines. Genetic profiling, such as with FoundationOne testing, provides genetic profiling to help guide therapeutic decision making. Accordingly, in this patients case, FoundationOne testing performed on 3/14/17 was likely to have been more effective than the standard methods of evaluating this patients medical condition. Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 54-year-old female enrollee has requested reimbursement for color-flow Doppler echocardiography performed on 3/29/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees chest pain and dyspnea. The physician reviewer found that the records document increased coronary risk and symptoms suspicious for coronary ischemia. Overall, the patients pre-test risk based on her risk factors, age and symptoms was at least moderate. In this circumstance, a test with increased sensitivity such as a stress echocardiogram is preferable and appropriate compared to a regular treadmill electrocardiogram with a reduced sensitivity of about only 60 to 70%.  In addition, the stress echocardiogram is able to assess for other potential causes of the patients exertional dyspnea, such as cardiomyopathy or occult valvular disease. Current guidelines endorsed by several national organizations also consider stress echocardiogram appropriate in this circumstance. The medical evidence supports the use of color-flow Doppler echocardiography in this patients case. In sum, color-flow Doppler echocardiography performed on 3/29/18 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a five-year-old female enrollee has requested authorization and coverage for therapeutic activities, direct (one on one) patient contact. 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 this patient has documented difficulties with motor coordination, postural stability, self-regulation, and fine/gross motor skills. With its focus on developing motor planning skills and self-help skills, developing age-appropriate communication skills, processing information, and regulating the response to incoming information, occupational therapy is an appropriate intervention strategy for this patient. Sensory-based interventions alone have not been demonstrated to be beneficial. However, it may be acceptable to incorporate sensory-based modalities into a comprehensive treatment plan. This patient has challenges that negatively impact her daily functioning, and occupational therapy is appropriate to address these challenges. The submitted documentation supports the requested services in this clinical setting. Therefore, therapeutic activities, direct (one-on-one) patient contact are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 40-year-old female enrollee has requested reimbursement for the Decision Dx test and specimen handling provided on 11/23/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by the staging system discussed by Balch and colleagues. Based on this study, a pT1a melanoma has an extremely good prognosis with a very low risk of recurrence. Decision Dx is the study of 31 genes in the melanoma cells and classifies the melanoma as Class 1, with a disease free state of 97% at five years, or Class 2, with a 31% disease free rate at five years. However, it has not been established in the scientific data that the Decision Dx findings can be used reliably to influence decision making in clinical practice. All told, the Decision Dx test and specimen handling provided on 11/23/15 were 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 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 61-year-old female with a left-sided thyroid nodule. Cytology from a fine needle aspiration biopsy was indeterminate. A specimen was subsequently sent for Afirma gene classifier analysis. The patient has requested reimbursement for the gene test provided on 12/21/16. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of this patient. While a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. Afirma gene classifier analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby avoiding unnecessary surgeries. Because it is sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the gene test provided on 12/21/16 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 42-year-old male enrollee has requested reimbursement for decompression procedure performed on 10/5/15. The Health Insurer has denied this request indicating that the procedure at issue is considered investigational for treatment of the enrollees occipital neuralgia.  The physician reviewer found that occipital neuralgia is a condition characterized by frequent and severe headaches characterized by paroxysmal stabbing pain in the distribution of the greater or lesser occipital nerves. The pain is located in the occipital area and may spread toward the vertex; it is usually unilateral but may be bilateral. The treatment plan for occipital neuralgia depends upon many factors, such as the severity of the dysfunction and pain, the type and location of the pain, as well as patients age, ongoing medical conditions, and ability to tolerate other medical therapies. Standard therapy may include medications to relieve pain and muscle spasms, localized injections, physical therapy, or massage. Surgical release of the greater occipital nerve has been demonstrated to be clinically effective in eliminating or reducing chronic migraine symptoms. However, migraine symptoms in some patients continue after this procedure. It was theorized that a different relationship between the greater occipital nerve and occipital artery may exist in these patients that may be contributing to these outcomes. Vascular pulsation may cause irritation of the nerve and is a possible explanation for migraine headaches that have the occipital region as a trigger point. Future imaging studies and clinical investigation is necessary to further examine the link between anatomy and clinical presentation. At this time, occipital release surgery warrants further investigation. As such, the decompression procedure performed on 10/5/15 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 procedure 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested reimbursement for inpatient care provided on 11/07/18. 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 the submitted documentation supports the medical necessity of the services at issue. By 11/07/18, the patient had been admitted for two days, but was not yet on a full liquid diet, and still had episodes of hypertension requiring intravenous hydralazine. He had just started having bowel movements and had the nasogastric tube removed the day before. In such cases, discharge on 11/06/18 or 11/07/18 would have been premature. The patient warranted confirmation that small bowel obstruction had been resolved, bowel function had returned to normal, and that he was able to tolerate sufficient oral intake to maintain nutrition before discharge, or there would be a high probability of readmission. Therefore, inpatient care provided on 11/07/18 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3   
A 63-year-old female enrollee has requested reimbursement for Guardant360 testing performed 
on 2/04/21. 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 is an important part of testing in breast cancer and can 
help direct treatment options. In this case, although the patient has a history of breast cancer, 
she appears to be in remission as her last documented therapy (2004) was 17 years prior to the 
Guardant360 test.  Although the recent imaging studies are concerning for recurrence, there is 
no  histologic  confirmation  of  her  disease.    National  Comprehensive  Cancer  Network  and 
American Society of Clinical Oncology guidelines for metastatic breast cancer recommend a 
tissue  biopsy  to  confirm  the  diagnosis  prior  to  treatment  planning.    Previous  notes  had 
mentioned BRCA1 positive disease, and so this positive finding on the Guardant360 testing would 
not confirm disease recurrence at the present time. Without prior confirmation of recurrent 
disease,  the  Guardant360  test  is  not  more  beneficial  than  standard  therapy.  Therefore, 
Guardant360 testing performed on 2/04/21 was not likely to have been more beneficial than any 
available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that a Non-small cell lung cancer, particularly adenocarcinoma, should be tested for a variety of mutations, including EGFR, ALK, ROS-1, KRAS, tumor mutational burden and microsatellite instability. Each of these has therapeutic implications. Ordinarily, these genomic assays are done on the tissue biopsy done for diagnosis. FoundationOne assay is an assay of more than 300 gene mutations, including those noted above. However, beyond the specific mutations noted above, there has been a lack of convincing data that the assays for the rest are of clinical benefit. The chance of benefit from therapy guided by such a general assay is small. Therefore, FoundationOne CDx test performed on 12/31/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement for the molecular profiling lab testing performed on 1/23/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic carcinoma of unknown primary site. The physician reviewer found that the determination of a patients primary site of an adenocarcinoma is of clinical importance in determining the most likely treatment to be efficacious. The use of genetic markers is likely to indicate the most likely primary site, and also to help guide treatment determinations (Weiss, et al; Hainsworth, et al). For these reasons, the molecular profiling lab testing performed on 1/23/15 was likely to be of greater clinical benefit than standard available testing. Based upon the information set forth above, I have determined 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 16-year-old female enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center services provided from 2/16/16 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 condition. The physician reviewer found the residential treatment center services provided from 2/16/16 forward were not and are not medically necessary for treatment of the patients medical condition. As of 2/16/16, the patient did not have any suicidal ideation. She did not have any mania, psychosis, or delusions. She was interactive with peers. She was engaged in her treatment and opening up more in group. Utilizing the Child and Adolescent Level of Care Utilization System (CALOCUS), the patients total score is a 15. This score correlates with a recommendation for outpatient treatment. The patient scored a two (2) on the risk of harm dimension as the patient had intermittent suicidal ideation without any prior history of suicide attempts. The patient had occasional impulsivity and had brief lapses in the ability to care for herself. The patient scored a two (2) in the functional status dimension as the patient had times where she would fast and/or restrict calories. However, there was no evidence that the patient was medically compromised or had any hypotensive episodes due to her lack of eating. The patient had no legal trouble, she attended school, and was cooperative with staff. The patient would demonstrate a significant improvement in functioning following a period of deterioration. The patient scored a two (2) in the co-morbidity dimension. The patient would have episodes of elevated anxiety which are moderately debilitating and would adversely affect the patient. The patient scored a three (3) in the environmental stress dimension. The patient moved to California and had a hard time adjusting. She was a victim of bullying and had frequent adverse interactions with her parents. The patient scored a one (1) in the environmental support dimension. Both parents were engaged and invested in the patients recovery and treatment. The patient scores a three (3) in the resiliency dimension. The patient has demonstrated inconsistent or equivocal capacity to deal with stressors, and recovery has been maintained for moderate periods of time, but only with strong professional support. The patient scored a two (2) in the engagement dimension. The patient is able to develop a positive relationship with providers. She passively cooperates in treatment planning and treatment. Given the patients total CALOCUS score of 15, as of 2/16/16, the patient can safely and effectively be treated at a lower level of care. For the reasons provided, 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 61-year-old male enrollee has requested authorization and coverage for proton beam radiation therapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees colorectal cancer with liver metastases. The physician reviewer found that there is no medical literature to suggest that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for rectal cancer (Allen, et al). There is no data submitted that suggests that treatment with proton techniques will be able to improve sparing of the small bowel compared to standard intensity modulated radiation or three-dimensional (3D) conformal techniques with photons. The National Comprehensive Cancer Network (NCCN) guidelines do not support the use of proton therapy in this clinical setting. In the majority of cases, treatment with photon techniques is advised, especially in the palliative setting. Moreover, there is a lack of level I evidence to support the use of proton therapy for the treatment of rectal cancer. Based on these reasons, the requested proton beam therapy 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 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old male enrollee has requested reimbursement for positron emission tomography (PET) performed on 3/08/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that based on the rising PSA levels, the patient had recurrence of his prostate cancer.  Regardless of imaging studies, rising PSA levels in a patient who has had what was felt to be definitive therapy for prostate cancer is unequivocal evidence of recurrence. If the recurrence is local, then this can be treated by external beam radiotherapy.  On the other hand, if the patient has distal metastases, the more optimal treatment is likely hormone deprivation therapy. The detection of early recurrence is often difficult.  Bone scans will be rarely positive in patients with PSA levels less than 10.  Plain x-rays will generally not detect a lesion until 50% of the bone mineralization is lost or gained (sclerotic metastases).  CT scans and MRI are dependent on the site scanned, and will only pick up gross anatomic distortions or disease.  Microscopic or small lesions will be very difficult to detect. In order to effectively cover the areas detectable by PET scanning, one would have to perform CT or MRI scans of the head, neck, chest, abdomen, and pelvis. The value of PET scanning, especially when combined with CT scans is that they depend on metabolic changes to detect abnormalities. In this patients case, the PET scan detected recurrence not appreciable by other modalities. Thus, PET performed on 3/08/18 was likely to have been superior over other available 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the services at issue were not likely to be more effective for this patient than any other available options. There is a lack of evidence-based research in the medical literature to support the services at issue. According to the American Academy of Child and Adolescent Psychiatry, It seems established that a pharmacological intervention for ADHD is more effective than a behavioral treatment alone. Additionally, the documentation submitted for review does not mention evidenced-based treatments tried such as parent training or social skills training. All told, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than standard treatment options. The Health Insurers denial should be upheld.