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

Summary Reviewer 

The patient is a 44-year-old female who has requested reimbursement for DecisionDx-Melanoma testing performed on 1/02/20.  The patient has requested reimbursement for unlisted multianalyte assay with algorithmic analysis performed on 1/02/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. 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. Prognostic gene expression profiling (GEP) testing to differentiate melanomas at low versus high risk for metastasis should not replace pathologic staging procedures. Moreover, since there is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive result, GEP testing should not guide clinical decision-making in this group. It remains unclear where these GEP platforms provide clinically actionable prognostic information when used in addition to or in comparison with known cliniopathologic factors or multivariate 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. Prospective validation studies are required to more accurately define the clinical utility of molecular testing prior to widespread implementation of GEP for prognostication of cutaneous melanoma, and in particular to determine its role in guiding surveillance imaging, sentinel lymph node biopsy, and adjuvant treatment decisions. Existing and emerging GEP platforms and other prognostic techniques should also be compared with optimized contemporary multivariable phenotypic models. Therefore, unlisted multianalyte assay with algorithmic analysis performed on 1/02/20 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 13-year-old male enrollee has requested reimbursement and prospective authorization and coverage for intensive behavior therapy (IBT) services provided from 2/02/16 through 8/02/16. 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 autism.   The physician reviewer found the submitted documentation supports the medical necessity of a portion of the services at issue.  ABA addressed social skills deficits, communication problems and adaptive delays.  Per the submitted records, this patient has autism spectrum disorder and has been making progress with ABA therapy.  In this patients case, 25 hours of ABA therapy per week is medically appropriate and standard of care.  Additionally, one hour of supervision for every eight to ten hours of direct ABA is medically indicated.  In sum, the records demonstrate the medical necessity of a portion of the services at issue in this patients case.  Therefore, a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 62-year-old male enrollee has requested authorization and coverage for positron emission tomography (PET) scan.  The Health Insurer has denied this request indicating that the requested services are considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this clinical setting.  The medical evidence supports up to three PET scans for all solid tumors including multiple myeloma for staging, restaging and surveillance.  Per the current guidelines, the most sensitive imaging test to detect active or recurrent myeloma is positron emission tomography/computed tomography (PET/CT).  Thus, the requested PET scan is likely to be superior over other modalities for evaluating this patient.  Based upon the information set forth 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: Experimental
Decision: Upheld

Summary Reviewer 2
A 73-year-old male requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.  The physician reviewer found that the patient is a 73-year-old male who was diagnosed with locally recurrent invasive squamous cell carcinoma, moderately, differentiated midline frontal, anterior and posterior, shave incision. A sample specimen was submitted for next generation sequencing using FoundationOne. The patient requested reimbursement for genetic testing performed on 9/26/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational.As noted by the National Comprehensive Cancer Network (NCCN), current therapy and achieved outcomes for metastatic lung cancer is not based on panel testing. In general, to demonstrate clinical utility of panel genetic testing such as FoundationOne, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. However, there is a lack of published trials demonstrating that use of genetic panel testing such as FoundationOne to direct treatment results in improved patient outcomes. The available literature on clinical utility consists of a small number of uncontrolled studies and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the FoundationOne testing provided on 9/26/16 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 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 52-year-old male enrollee has requested reimbursement for ExoDx Prostate/ExosomeDx 
Prostate (Intelliscore) performed on 12/23/20. 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. This patient has a family history of prostate cancer and a rising 
PSA level. The use of ExoDx Prostate/ExosomeDx Prostate (Intelliscore) provided additional 
guidance to assess the acute need for biopsy which was unattainable by PSA factors alone. The 
medical literature supports the services at issue in this clinical scenario to further evaluate at-
risk individuals. The ExoDx Prostate/ExosomeDx Prostate (Intelliscore) was a non-invasive 
method to guide care in this case. Therefore, ExoDx Prostate/ExosomeDx Prostate (Intelliscore) 
performed on 12/23/20 was likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 37-year-old female enrollee has requested authorization and coverage for an implanted electrical stimulator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees pain. The physician reviewer found that there is support for the requested device in this patients case. This patient has ongoing cervical radiculopathy despite cervical spine surgery, and she has failed postoperative measures, including medication management and activity modification. The requested device is standard of care for the treatment of the patients medical condition. In sum, the requested implanted electrical stimulator is likely to be more effective for treatment of the patients condition than other available treatment options. Based upon the information set forth above, the requested device 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: Overturned

Summary  
The  patient  is  a  36-year-old  female  with  a  history  of  oromandibular  dystonia,  bilateral 
temporomandibular joint (TMJ) pain, and migraine without aura or without status migranosus, not 
intractable. The provider has recommended botulinum toxin (Botox) injections for oral mandibular 
dystonia to include the temporalis muscle, masseter muscle, and cervical paraspinals. The Health 
Insurer has denied the requested medication as not medically necessary. This denial is the subject 
of this appeal and determination. The physician reviewer found that on review of the available 
records,  this  patient  presents  with  a  history  of  oromandibular  dystonia.  The  provider  has 
recommended injecting Botox into the muscles that are contributing to the patients dystonia. 
Based on the current peer-reviewed medical literature, Botox is considered a first-line treatment 
for the management of patients with oromandibular dystonia. As noted by Deik and colleagues, 
oromandibular dystonia is characterized by involuntary movements involving masticatory, lingual, 
and  pharyngeal  muscles.  Oromandibular  dystonia  can  manifest  as  tongue  protrusion,  jaw 
clenching, jaw opening, and/or jaw deviation. In addition, oromandibular dystonia is oftentimes 
found in combination with dystonia of adjacent body regions, including blepharospasm, cervical 
dystonia, TMJ pain (Hassell and Charles). Botox has been demonstrated to be a safe and effective 
first-line therapy for the treatment of many dystonic syndromes. A number of large safety studies 
have reported data demonstrating the efficacy of Botox without significant long-term side effects. 
Given this support, the requested Botox 200 unit vial is medically necessary for treatment of this 
patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 17-year-old male enrollee has requested reimbursement for acute psychiatric inpatient treatment provided from 5/23/19 through 5/26/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. In terms of risk of harm, the records support a score of 4 due to his recent pattern of explosive behaviors. With regards to functional status, the records support a score of 5 due to serious deterioration of interpersonal interactions due to psychotic symptoms. In terms of comorbidity, the records support a score of 4 due to significant psychiatric symptoms that impair functioning in the absence of stressors. With regards to level of stress of the recovery environment, the records support a score of 2 due to a stable home environment. In terms of level of support of the recovery environment, the records support a score of 2. The patient is able to return to home, but may attend residential treatment due to symptoms. With regards to resiliency and treatment history, the records support a score of 5. The patient has not demonstrated significant remission of symptoms in the recent past despite treatment with numerous medications and electroconvulsive therapy. In terms of acceptance and engagement of the patient, the records support a score of 5. The patient showed almost no insight into his behaviors due to his level of impairment. With regards to acceptance and engagement of the parent, the records support a score of 2. The parents appeared to work well with clinicians. Thus, the patient has a composite score of 29. This score correlates with secure 24-hour services with psychiatric management. An example of this is a hospital or secure residential treatment center. Per the records, the inpatient setting was the least restrictive environment for the patient due to continued acute symptom presentation. Therefore, acute psychiatric inpatient treatment from 5/23/19 through 5/26/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 43-year-old female enrollee has requested authorization and coverage for right sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back pain.   The physician reviewer found this patient presents with a history of right SI joint pain which is reported as severely debilitating. She has been diagnosed with sacroiliitis. There is no history of trauma. Clinical exam findings are generally consistent with SI joint pathology with positive FABER test, but do not document three positive exam findings consistent with evidence based medical guidelines. Right SI joint injections have provided greater than 50% improvement in pain. However, there are no imaging findings documented relative to the right SI joint that confirm sacroiliitis due to spondyloarthropathy. In addition, detailed evidence of a failure of conservative treatment has not been submitted. Moreover, there is an absence of evidence based medical peer-reviewed support for SI joint fusion for low back pain and lack of clear diagnostic findings isolated to the SI joint. For these reasons, the requested SI joint fusion 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: Medical Necessity
Decision: Overturned

Summary  
The patient is a 49-year-old male with a history of hypogonadism based on low testosterone levels. The 
records available for review indicate that the patient has been undergoing treatment with testosterone 
replacement therapy since 2015 with good clinical response. The physician reviewer found that at issue 
is whether the requested testosterone 1.62% transdermal gel is medically necessary for the treatment 
of this patient. Low testosterone can lead to complications such as reduced libido, erectile dysfunction, 
reduced muscle mass and strength, increased adiposity, osteoporosis, depressed mood, and fatigue 
(Marcelli and Mediwala). Numerous formulations have been approved for the treatment of patients 
with hypogonadism, including testosterone injections and transdermal gels (Lo, et al.). Transdermal gel 
provides a relatively steady level of serum testosterone as compared to testosterone injections, which 
may cause instabilities in symptoms due to fluctuations in serum testosterone levels (Surampudi, et al.). 
In this case, the patient presents with a history of hypogonadism based on low testosterone levels. The 
records indicate that the patient has been undergoing successful treatment with testosterone 
replacement therapy for several years, with his total testosterone levels improving from 240 ng/dL to 
the 400-500 ng/dL range. Moreover, the medical literature has established the efficacy of transdermal 
gel for the treatment of patients with hypogonadism. For these reasons, the requested testosterone 
1.62% transdermal gel is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 




A 27-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential mental health treatment provided from 6/14/16 through 1/31/17. 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 considering the extent of the patients thought disorder and the common practice of utilizing the residential setting as a step-down level of care, the initial admission was consistent with current practice standards. The patient showed fairly prompt signs of improvement. On 6/29/16, the patient was in a good mood. He was gaining insight, and his judgment was improving. His thought processing was linear. On 7/8/16, he was in good spirits and his psychotic symptoms were subsiding. On 7/14/16, his thought content was devoid of suicidality. His responses were appropriate. He was euthymic and organized with improving insight and judgment. The patient was medication adherent and self-administering his paliperidone and l-mehtylfolate. The patient was functioning independently, and by 7/14/16 had been in an inpatient setting for nearly three months. Based on the documentation provided, the patient warrants ongoing comprehensive specialty care including antipsychotic therapy, assertive community treatment, family psychoeducation, cognitive remediation, cognitive behavioral therapy, and supportive housing and employment. However, these services could have been delivered in a community-based setting while the patients illness burden no longer demanded placement in a 24-hour supervised setting as of 7/14/16. As such, discharge to a less restrictive setting by 7/14/16 would have been safe, appropriate and consistent with good medical practice. Thus, the residential mental health treatment provided from 6/14/16 through 7/13/16 was medically necessary.Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 17-year-old female with a history of migraines and postural orthostatic tachycardia syndrome. The provider noted that the patient has a constellation of multisystem involvement consistent with a diffuse metabolic disorder with abnormal lactate and pyruvate levels. The records document that a mitochondrial disorder was considered. The provider noted that that establishing a diagnosis was important because management would be altered. The Health Insurer has denied reimbursement for genetic testing (mitochondrial genome sequencing) performed on 12/31/16. Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  Molecular genetic diagnostic testing for mitochondrial disease has evolved continually since the first genetic basis for a clinical mitochondrial disease syndrome was identified in the late 1980s. Diagnosis via genetic testing for mitochondrial disease involves newer technologies and are the new gold standard methodology for mitochondrial DNA genome sequencing. In the absence of clear-cut genotype-phenotype correlations, biochemical analyses are the cornerstone of the diagnosis of this condition. In this case, the clinical picture was consistent with a mitochondrial DNA disorder. Thus, the services at issue were appropriate in this setting. In sum, genetic testing (mitochondrial genome sequencing) performed on 12/31/16 was 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 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 24-year-old female enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found that IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based on the medical records provided for review, the patient presents with a large mediastinal mass which requires radiation. The patient has an excellent long term survival, upwards of 90%, and therefore all efforts should be made to mitigate long term toxicities from radiation therapy which include heart and lung damage. IMRT can be utilized to minimize dose to the surrounding heart and lungs. Comparative planning between IMRT and three-dimensional (3D) conformal treatments were submitted for review. They reveal that the IMRT plan is able to significantly reduce radiation dose to the heart and lungs which will decrease the incidence of long term toxicities seen in these organs. The National Comprehensive Cancer Network (NCCN) guidelines state that IMRT can be used in treatment of patients with Hodgkin's disease. Furthermore, there are comparative studies which have demonstrated that IMRT reduces the radiation dose compared to older methods of delivering radiation such as 3D conformal techniques (Filippi, et al; Lu, et al). Therefore, IMRT is likely to be more beneficial for treatment of this patients Hodgkins disease than any available standard therapy. Based upon the information set forth above, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.