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

Summary Reviewer 2

A 58-year-old female enrollee has requested reimbursement for Afirma Thyroid Fine Needle Aspiration Analysis gene testing performed on 11/18/14. 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 that the submitted documentation fails to demonstrate the superior efficacy of the services at issue in this patients case.  In this case, the cytopathology report was consistent with suspicion of follicular neoplasm. This finding carries a risk of malignancy of 35%.  The genetic marker was consistent with suspicion for malignancy, which raises the risk of malignancy to 40%.  Submitting the specimen to Afirma testing was useful to confirm the recommendation for surgery.  However, it did not change the risk to change the recommendation.  In sum, Afirma testing did not provide additional benefit to the patient which would have altered patient management.  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: Upheld

Summary Reviewer 3

A 26-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 4/15/19. 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 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 DecisionDx-Melanoma testing 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. Therefore, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 31-year-old male with rectal bleeding and pain with bowel movements since July 2020 who has been diagnosed with an anal fissure. The patient has requested authorization and coverage for Botox (onabotulinumtoxinA for injectable 100 unit). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that Botox injection is a standard of care treatment option for fissures that do not respond to medical management. According to the Clinical Practice Guideline for the Management of Anal Fissure from the American Society of Colon and Rectal Surgeons, Compared with topical nitrates, the use of calcium channel blockers for chronic anal fissures has a similar efficacy, with a superior side effect profile, and can be used as first-line treatment. The guideline also notes, Botulinum toxin has similar results compared with topical therapies as first-line therapy for chronic anal fissures, and modest improvement in healing rates as second-line therapy following treatment with topical therapies. It is not standard of care to require treatment with both nitroglycerin and a calcium channel blocker. Botox is a standard treatment option for fissures that do not respond to medical management. An alternative to Botox is lateral internal sphincterotomy, but this has potential for complications, including fecal incontinence. It is medically appropriate to pursue Botox injections prior to consideration for surgery. Therefore, Botox (onabotulinumtoxinA for injectable 100 unit) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 62-year-old female who is status post mastectomy with lymph node dissection in June 2020. The patient has requested reimbursement for hospital admission provided from 9/29/20 through 10/01/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Schwartz stated, As surgical procedures become less morbid with decreased operative times, less postoperative pain, and quicker recovery, the benefits of hospital admission become less significant and same-day discharge is possible without compromising outcomes, patient safety, or satisfaction. Oxley and colleagues performed a study of same day discharge after immediate post-mastectomy alloplastic breast reconstruction. The authors noted, Any patients with high-risk anesthetic histories, ASA III or above or significant sleep apnea are admitted for a planned overnight stay at the hospital. All other patients (ASA II or lower) are treated as same day discharge procedures, either at the hospital or day care clinicSame day discharge following IPMABR (immediate post-mastectomy alloplastic breast reconstruction) is safe and greatly reduces resource use. In this case, the patient developed an acute unilateral breast hematoma following previous subpectoral placement of a tissue expander. An arterial bleeder was identified, and the hematoma was evacuated in the operating room. She was admitted for two days of inpatient hospital stay. There is no history of intercurrent disease or of increased anesthesia or postoperative risk factors. No special postoperative monitoring was required, and her recovery was uneventful. Drainage was reduced markedly by the morning following the procedure. Based on the medical records received for review, there is no indication that inpatient hospital care was required as contrasted to observation care. Therefore, hospital admission provided from 9/29/20 through 10/01/20 was not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 40-year-old male with chronic left-sided low back pain. He has tried physical therapy as well as medications.  The patient has requested authorization and coverage for arthrodesis sacroiliac joint, percutaneous or minimally invasive. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that there is sufficient support for the requested services in this clinical setting. This patient has localized pain to the sacroiliac joint. This pain has responded to anesthetic injection, indicating that the sacroiliac joint is the pain generator. The patient has failed reasonable nonsurgical treatments, and the current high-level evidence supports minimally invasive fusion to have superior outcomes to further conservative care. Therefore, arthrodesis sacroiliac joint, percutaneous or minimally invasive is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 55-year-old male enrollee has requested reimbursement for partial hospitalization program (PHP) services provided from 8/15/16 through 9/21/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the the PHP services provided from 8/15/16 through 9/21/16 were not medically necessary. Although chemical dependency treatment was clinically indicated, the record does not support the medical necessity for PHP level of care during the dates in dispute. On 8/15/16, the patient reported no depression, inattention, anxiety or suicidality. He was eating 100% of his meals, sleeping 10 hours per night and he was not prescribed psychotropic medication. He did not have psychiatric or medical co-morbidity. He was actively engaged in treatment and looking forward to being drug free. In sum, the record does not demonstrate that comprehensive, evidence-based services provided in an outpatient program would have been unsafe or inadequate to address this patients medical condition. All told, the patient could have been treated at a less restrictive setting as of 8/15/16. Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 58-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus genotype 1b.  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. Based on the foregoing discussion, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 58-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 7/10/15.  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 the medical literature supports breast tomosynthesis in this patients case.  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 noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the breast tomosynthesis performed on 7/10/15 was likely to have been more effective than other modalities for 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: Overturned

Summary Reviewer 1

A 64-year-old male enrollee has requested reimbursement for PET scan performed on 8/31/18. 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 there is sufficient support for the services at issue in this clinical setting. The use of positron emission tomography (PET) scans in staging and restaging colon cancer has been proven to be more sensitive for residual or recurrent colon cancer than computed tomography (CT) or magnetic resonance imaging (MRI) alone. The physiologic activity of metastases or local recurrence makes PET a more sensitive test for tumor than conventional imaging. The PET scan on 8/31/18 followed a conventional CT and was indicated for the patients condition. Therefore, PET scan performed on 8/31/18 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 29-year-old male enrollee has requested reimbursement for chiropractic services provided on 2/03/16, 2/08/16 and 2/15/16.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees spinal enthesopathy, segmental and somatic dysfunction of cervical region, and sprain of ligaments of thoracic spine. The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The clinical records do not support the need for the chiropractic services provided on 2/03/16, 2/08/16 and 2/15/16.  The records note that the patient was receiving additional units of therapy in addition to spinal and extraspinal manipulation per visit.  This is considered excessive, and the medical evidence does not support the services at issue in this clinical setting.  There is a lack of high-grade scientific evidence to support passive physical modalities such as traction and massage/myofascial release for neck and upper back complaints.  All told, chiropractic services provided on 2/03/16, 2/08/16 and 2/15/16 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 63-year-old female enrollee has requested authorization and coverage for an iris prosthesis. 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 medical records state that the patient has advanced glaucoma. The patient says that she has a glare from her traumatic aniridia. She also states that she desires to undergo this procedure to improve the cosmetic appearance of her abnormal eye. In this patientas case, placement of an iris prosthesis is unlikely to improve her functional vision; there is a greater chance that significant complications may result. She currently uses a custom contact lens, without apparent complications. Therefore, the requested iris prosthesis is not likely to be more beneficial for the treatment of this patient than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. 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 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 DecisionDx-Melanoma testing 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. Thus, DecisionDx-Melanoma testing performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 62-year-old male enrollee has requested reimbursement for gene testing for prostate cancer performed on 4/21/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the testing at issue was not likely to be more effective for this patient than other available treatment options. Bostrom and colleagues performed a literature review of the use of genomic biomarkers in the prognostication of prostate cancer outcome and prediction of therapeutic response. The authors indicated that genomic testing in prostate cancer is in its infancy and it is yet unknown how to use results in clinical practice. Moreover, the patient was determined to be at an intermediate risk, based on Gleason score of 7. Per National Comprehensive Cancer Network (NCCN) guidelines, viable options for treatment include prostatectomy or pre radiation androgen deprivation therapy, followed by radiation therapy. For the reasons provided, the genomic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the 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: Upheld

Summary Reviewer 3


A 51-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/15/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found this patient had symptoms, primarily diarrhea, while on Remicade suggestive of loss of response.  Inadequate response or loss of response can occur for many reasons.  However, the appropriate method for determination of cause for symptoms while on therapy is not clear.  The use of Anser IFX to investigate inadequate response and direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management.  The effectiveness of Anser IFX in management of Crohns disease compared to conventional courses of action remains unproven in controlled clinical trials.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient, with many patients who have these antibodies maintaining their response.  In sum, the superior efficacy of Anser IFX testing performed on 4/15/14 has not been established.  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


A 59-year-old female enrollee has requested reimbursement for breast tomosynthesis performed on 9/26/16.  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 that 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 breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3 
 
A 58-year-old male enrollee has requested reimbursement for therapeutic phlebotomy from 
1/6/21 through 1/26/21. The Health Insurer has denied this request and reported that the service 
at issue was investigational for the treatment of the enrollees hereditary hemochromatosis. The 
physician  reviewer  found  that  hereditary  hemochromatosis  is  an  inherited  disorder  most 
commonly caused by a point mutation in the HFE gene, typically C282Y, or less commonly by 
other genes related to iron regulation such as H63D. Most of these disorders result in increased 
intestinal iron absorption that can eventually cause serious tissue damage. The goal of treatment 
in hereditary hemochromatosis is to prevent organ dysfunction from excess iron and/or to 
improve organ function if it has already been affected. Patients with iron overload, or at risk for 
iron overload, are treated with phlebotomy. Patients who cannot tolerate phlebotomy, for 
example, due to concomitant anemia, may be treated with an iron chelator instead if their iron 
overload is significant. Patients without iron overload who have a hereditary hemochromatosis 
genotype, such as homozygosity for HFE C282Y or compound heterozygosity for C282Y and 
another HFE variant, may be monitored regularly. The American College of Gastroenterology 
supports phlebotomy for hereditary hemochromatosis with evidence of iron overload. In this 
case, the patient has evidence of iron overload with organ damage based on liver biopsy result 
and MRI of the liver. Therefore, therapeutic phlebotomy from 1/6/21 through 1/26/21 was likely 
to have been more beneficial for treatment of the enrollee's condition than any available 
standard therapy.