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

Summary Reviewer 

The patient is a 46-year-old female with a history of anxiety and depression and eating disorder. The patient has been prescribed bupropion (Wellbutrin) since at least 1997. She has been doing well with brand name Wellbutrin. A trial of generic bupropion reportedly lacked efficacy and tolerability, and required treatment with diphenhydramine for a possible allergic reaction. The patient has been treated with other psychotropic medications including venlafaxine, fluoxetine, trazodone, aripiprazole and buspirone without substantial improvement. The provider has ordered continuing therapy with brand name Wellbutrin XL. The patient has requested reimbursement and prospective authorization and coverage for brand name Wellbutrin XL from 3/9/17 forward. The Health Insurer has denied this request indicating that the medication at issue was not and is not medically necessary. Bupropion is a dual-acting medication that enhances both noradrenergic and dopaminergic tone in the central nervous system that was approved by the U.S. Food and Drug Administration (FDA) for treatment of depression in 1989. An extended release (XL) formulation was approved in 2003. In the medical literature, Sadock and colleagues noted that the possibility exists that differences in potency may underlie adverse changes in clinical status, when a brand name medicine is substituted with a generic, or even if there is a switch between specific generic manufacturers. This patient has been clinically stable on an evidence based antidepressant medication endorsed by current practice guidelines and community standards. The patient previously failed treatment with various medications as well as a trial of generic bupropion. All told, the brand name Wellbutrin XL provided from 3/9/17 forward, was and is medically necessary as it is reasonably expected to maintain the patients clinical stability and prevent an exacerbation of illness. Based on the available documentation, the medication at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2 
A 52-year-old female enrollee has requested reimbursement for BCR-ABL gene rearrangement 
quantitative polymerase chain reaction (PCR) testing, BCR-ABL fluorescent in situ hybridization 
(FISH) performed on 11/21/22. The physician reviewer found that evaluation of a blood count 
with review of peripheral smear may warrant further testing with BCR-ABL. However, this 
patients records do not include clinical documentation to support an indication for BCR-ABL PCR 
or FISH testing. Elevated peripheral blood cell counts, such as leukocytosis, thrombocytosis, and 
polycythemia, are often the presenting symptom in a patient with a myeloproliferative neoplasm 
(MPN). Since cythemias are nonspecific and may reflect either a reactive or neoplastic process, 
diagnostic  work-up  requires  integration  of  numerous  diagnostic  modalities.  Wong  and 
Pozdnyakova noted that, Although certain mutations are preferentially enriched in specific MPN 
types, none of these mutations are disease defining; therefore, a thorough work-up should 
always include a bone marrow biopsy for morphologic evaluation and diagnosis. Moreover, 
patients with rheumatoid arthritis can present with elevated white blood counts for a variety of 
reasons and does not merit the BCR-ABL PCR and FISH testing performed in this patients 
evaluation in lieu of standard testing. Therefore, the BCR-ABL gene rearrangement quantitative 
PCR testing, BCR-ABL FISH performed on 11/21/22 was not likely to be more beneficial for 
treatment of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 39-year-old male enrollee has requested reimbursement for the inpatient hospital stay services provided from 9/21/15 through 9/27/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees degenerative disc disease (DDD) with herniations. The physician reviewer found the current medical literature with regard to two level total disc replacement in the lumbar spine includes varying outcomes. In a recent article published by Trincat and colleagues, the authors noted that two level lumbar disc replacement can improve spinal function while preserving its mobility but the procedure is fraught with risks and complications. Thus, longer follow-up is needed to evaluate the sustainability of the results and to detect any adjacent segment disease. A high-quality meta-analysis and health technology assessment concluded that there is insufficient evidence to draw extensive efficacy conclusions comparing artificial disc replacement with a broad range of recommended treatment options in the lumbar spine (Park, et al). All told, the efficacy remains uncertain and inadequate evidence exists to establish long-term benefits or harms. For these reasons, the inpatient hospital stay services provided from 9/21/15 through 9/27/15 were not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary  
The patient is a 58-year-old female who fell from a horse while in Mexico on 7/27/22. The patient 
sustained bilateral rib fractures and bilateral pneumothoraces. The patient was transferred by air 
ambulance from Mexico to a facility in San Francisco, California. The Health Insurer has denied 
the air ambulance services as not medically necessary for treatment of the patients medical 
condition. This denial is the subject of this appeal and determination. The physician reviewer found 
that the air medical transport is considered medically necessary when the patients condition is life-
threatening such that any form of transportation other than ambulance would be medically 
contraindicated, the time needed to transport by ground poses a threat to the patients survival, and 
the patient is transported to the nearest hospital with appropriate facilities for treatment. When 
transporting from one hospital to another, the air medical transport criteria must be met, and the 
initial hospital must not have the required services and facilities available to treat the patient. In 
this case, the patient had been admitted in the initial hospital in Mexico for seven days. The records 
do not document that the patient had a flail chest or required emergent rib fixation. The initial 
hospital had already managed the left pigtail catheter for seven days, and the patients pain was 
controlled. For these reasons, the air ambulance  services were not medically necessary for 
treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. 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 currently are three major approaches to the management of localized prostate cancer. These are surgical prostatectomy, forms of radiation therapies, and active surveillance, with no specific anti-cancer treatment given. The treatment recommendation is based on risk stratification, which is a methodology combining pathologic and clinical features. In this case, the patient would be classified as being in the favorable intermediate risk category, for which it is not entirely clear what recommendation should be made. The National Comprehensive Cancer Network suggests using genomic assays as an adjunct to treatment decisions in this risk category. Oncotype DX assay is a 17-gene assay that is capable of assessing risk of recurrent disease. In this patients case, adding Oncotype assay to his evaluation was likely to have been beneficial. Therefore, Oncotype DX testing performed on 4/25/19 was likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for the IgG food sensitivity testing provided on 2/10/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees abdominal discomfort. The physician reviewer found based on the current literature and guidelines that address IgG diagnostic testing, IgG food sensitivity testing is not considered a clinically useful, relevant, or valid method for evaluation of abdominal discomfort, or for identifying food allergy or food intolerance that may be contributing to abdominal discomfort or other gastrointestinal symptoms. IgG and IgG subclass antibody tests for food allergy related conditions do not have clinical relevance and lack sufficient quality control, and should not be performed (Boyce, et al). All told, the IgG food sensitivity testing performed on 2/10/16 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 testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 20-year-old male with significant daytime frequency every hour and nocturia every four to six hours. The patient reportedly also has insomnia. The patient has tried pelvic floor muscle rehabilitation as well as multiple medications including oxybutynin, Vesicare, and Myrbetriq. The patient experienced side effects and no substantial improvement in his symptoms with these therapies. The patient is currently on desmopressin with some improvement. The patient has requested reimbursement for percutaneous tibial nerve stimulation (PTNS) provided on 10/16/17. The Health Insurer has denied this request indicating that the service at issue was considered investigational. It was suggested that this patient undergo treatment with PTNS therapy for significant urinary frequency. The records document treatment failure with multimodal primary and secondary treatments for his condition. He does not wish to proceed with sacral neuromodulation or Botox injections. As noted in the medical literature, PTNS is performed as a salvage procedure. For these reasons, the PTNS provided on 10/16/17 was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 68-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees atrial fibrillation. The physician reviewer found that the Watchman device is an effective and relatively safe option for patients with atrial fibrillation who require but cannot take long-term anticoagulation. However, this patient underwent successful atrial fibrillation ablation with no documented recurrence of atrial fibrillation when the device had been regularly interrogated. Therefore, long-term anticoagulation would not be indicated to justify the need for a Watchman device. Thus, the superior efficacy of the requested percutaneous transcatheter closure of the left atrial appendage with endocardial implant (Watchman device) has not been demonstrated. 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 3

The parent of a 13-year-old male enrollee has requested authorization and coverage for Privigen. The Health Insurer has denied this request and reported that the requested medication is investigational for the treatment of the enrollees medical condition. The physician reviewer found that while PANDAS is not a diagnosis that has held up to careful scrutiny, autoimmune encephalitis with a vast range of neuropsychiatric symptomatology has. Additionally, the diagnosis of methylene tetrahydrofolate reductase (MTHFR) deficiency may manifest as isolated neuropsychiatric disease.  Given that this patient has been closely followed for MTHFR and will continued to be monitored for homocysteinemia and treated appropriately with B9, B12 and betaine if this becomes problematic, his clinical response to Privigen (IVIG) has been sufficient to justify its continued use for his recurrent neuropsychiatric symptomatology that is presumably due to his autoimmune encephalitis. There is support for the requested medication in this clinical setting. Thus, Privigen is likely to be more beneficial than other available treatment options.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 51-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 10/16/18. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines state while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy. The current medical evidence does not support the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma assay performed on 10/16/18 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 67-year-old male who was diagnosed with melanoma. The patient has requested reimbursement for DecisionDx-Melanoma testing performed on 1/01/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. The physician reviewer found that this patient has an early stage melanoma. Gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing performed on 1/01/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/17/15 and 1/12/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis studies performed on 12/17/15 and 1/12/16 were likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.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 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that overall, the use of fluciclovine PET is likely to be more beneficial in the management of the above patient when compared to standard techniques of evaluating this patients medical condition. 18F-fluciclovine was U.S. Food and Drug Administration approved in 2016 for the patients specific clinical scenario of suspected recurrent prostate cancer in patients with elevated PSA after prior therapy (Zanoni et al). The most recent National Comprehensive Cancer Network (NCCN) guidelines support its use in this setting (recurrent or persistent disease after initial treatment), specifically stating that F-18 fluciclovine PET/CT may be used to detect small volume disease in soft tissue. Performance is generally poor when PSA < 2.0ng/mL. Of note, the PSA for the above patient is 2.5 ng/mL.  The studies have shown that fluciclovine PET is more sensitive to detecting residual prostate cancer than bone scan or conventional computed tomography (CT) (Schuster, et al). Akin-Akintayo and colleagues specifically evaluated the use of fluciclovine PET/CT and its influence on postoperative radiotherapy treatment fields in patients with recurrent prostate cancer. They found that the results of a fluciclovine PET changed the radiation fields in 40.5% of the evaluated patients. Additionally, 4.8% of patients had radiotherapy withheld after the discovery of extra pelvic disease. There is a significant chance that fluciclovine PET will influence the patients salvage radiotherapy. All told, PET (CPT code 78813) scan is likely to be more effective for the evaluation of this patient as compared to conventional techniques. Therefore, for the reasons stated above, the requested services are 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 patient is a 16-year-old male with diagnoses of other specified anxiety disorder, cannabis use disorder, severe, and parent-child relational problem. He started using marijuana in eighth grade, and was using daily by the end of eighth grade. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to binge or excessive use of alcohol or other drugs, resulting in potentially harmful behaviors. In terms of functional status, the records support a score of 3. The documentation indicated moderate functional impairment, due to conflict with parents, recent sobriety and stabilization of mood achieved in a structured and protected setting (wilderness treatment program). With regard to comorbidity, the records support a score of 3. The documentation indicated significant comorbidity due to significant anxiety symptoms contributing to substance use. In terms of level of stress of the recovery environment, the records support a score of 1. The patient had a minimally stressful environment, due to the absence of difficulties in his life circumstances. With regard to environmental support, the records support a score of 2 due to his parents active participation in treatment and ability to meet patients material needs. In terms of resiliency and treatment history, the records support a score of 3 due to maintenance of abstinence and mood stability in the structured environment of the wilderness program, with no prior attempts at outpatient treatment. With regard to the patients acceptance and engagement, the records support a score of 2 due to his active participation in treatment at the wilderness program. Thus, the patient has a composite score of 17. This is consistent with an intensive outpatient or partial hospital program. There is no evidence that this level of care had been tried for this patient. Therefore, mental health residential treatment provided from 5/06/19 through 12/31/19 was not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 60-year-old female 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 melanoma. The physician reviewer found that this patient has an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and SLNB status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures. There is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma, and this test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. All told, DecisionDx-Melanoma testing performed on 4/15/19 was not likely to have been more beneficial than other methods of evaluating this patient.