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

Summary Reviewer 2


A 42-year-old female has requested reimbursement for Anser IFX Assay testing performed on 10/26/15. 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 there is a lack of support for the services at issue in this clinical setting.  Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of infliximab or the presence of infliximab antibodies have an adverse effect on the clinical outcome of a patients response to treatment.  However, while there have been testimonials, there are few well-controlled clinical trials to confirm that use of the Anser IFX Assay testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  In sum, Anser IFX Assay testing was not likely to have been superior over other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 25-year-old female has requested authorization and coverage for intravenous ceftriaxone.  The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of support for the requested medication in this clinical setting.  She underwent 28 days treatment with intravenous ceftriaxone following oral therapy.  The most recent guidelines for the treatment of Lyme disease do not recommend prolonged or repeated therapy for the same episode of Lyme.  Per the medical evidence, central nervous system Lyme disease should be treated with a duration of 14 days, with a range of 10 to 28 days.  This patient was treated with two weeks of ceftriaxone followed by another 28 days.  The medical evidence does not support the requested medication in this case.  Thus, the requested intravenous ceftriaxone is not likely to be superior over other treatment alternatives.  Based upon the information set forth above, the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that SMA is an autosomal recessive disease characterized by degeneration of spinal cord motor neurons that leads to atrophy of skeletal muscle and overall weakness. The disorder is caused by a mutation in the gene known as the survival motor neuron gene (SMN1), which is responsible for the production of a protein essential to motor neuron function. Because of the severity and relatively high carrier frequency, there has been increasing interest in carrier screening for spinal muscular atrophy in the general prenatal population. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for SMA in all women who are considering pregnancy or are currently pregnant. However, fragile X syndrome is the most common inherited form of intellectual disability. Fragile X premutation carrier screening is recommended for women with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant. However, fragile X testing is not recommended in the absence of family history. For these reasons, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


An 82-year-old female enrollee has requested authorization and coverage for Elidel 1% cream. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees decubitus wound on the lateral aspect of the left foot.   The physician reviewer found this patient was diagnosed with an inflammatory skin condition consistent with atopic dermatitis. The records provided for review document that the patient was treated with multiple modalities including topical steroids without substantial improvement. In this clinical setting, the continued use of Elidel is indicated. Therefore, the requested Elidel 1% cream is supported as medically necessary for treatment of this patients persistent skin condition. Based on these findings, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 19-year-old female enrollee has requested reimbursement for the Anser IFX test provided on 2/16/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear with continued treatment. The reasons for therapeutic failures remain unclear.  However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). Currently, it has not been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, as appears to apply in this case to this patients asymptomatic setting at the time of Anser testing. For these reasons, the Anser IFX test provided on 2/16/16 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 1

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that this patient had a stroke at a young age without documented other risk factors. He is in normal sinus rhythm. A transesophageal echocardiography showed evidence of a patent foramen ovale. Anticoagulation therapy would need to be lifelong, with a significant bleeding risk. The current medical evidence supports closure of a shunting patent foramen ovale, especially in younger patients with cryptogenic stroke in whom all other stroke etiologies have been effectively ruled out. Given the documented history of stroke, the lack of other identifiable causes of stroke, and otherwise the need for long-term anti-coagulation in this younger patient, the requested heart surgery (93580, percutaneous transcatheter closure of heart defect) is likely to be of greater benefit than other treatment options. 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.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 32-year-old female enrollee has requested reimbursement for bilateral breast magnetic resonance imaging (MRI) performed on 1/28/18. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who tested positive for BRCA1 mutation. The physician reviewer found that patients who have a BRCA mutations have been shown to have an extraordinarily high incidence of both breast and ovarian carcinoma. As such, this patient has undergone a diligent screening regimen, interrupted only by her pregnancy. Breast MRI has an important role in both screening and diagnostic settings. The current medical evidence supports the services at issue in this clinical setting. In sum, bilateral breast (MRI) performed on 1/28/18 was likely to have been more effective 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: Upheld

Summary Reviewer 2

A 55-year-old male enrollee has requested authorization and coverage for heart surgery (93580, percutaneous transcatheter closure of heart defect). The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees patent foramen ovale. The physician reviewer found that the submitted records fails to demonstrate the superior efficacy of the requested services in this clinical setting. In this circumstance, while there is increasing evidence to suggest that patent foramen ovale device closure may more effective than medical therapy alone for select patients age 60 years or younger with a cryptogenic non-lacunar ischemic stroke who have a patent foramen ovale, the patients most likely to benefit are those with large right-to-left interatrial shunting and/or an associated atrial septal aneurysm, neither of which is documented in this patient. Based on the documentation, medical management with aspirin is most appropriate in this case. In sum, heart surgery (93580, percutaneous transcatheter closure of heart defect) is not likely to be more efficacious than other treatment options. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 41-year-old male enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. This patient has been diagnosed with sacroiliac joint dysfunction. The records document physical examination findings which localize his symptoms to the sacroiliac joint. However, these findings are nonspecific in the presence of chronic low back pain. There are no objective imaging or laboratory findings to indicate the presence of sacroiliac joint infection, tumor, sacroiliitis due to spondyloarthropathy, or posttraumatic arthritis. Although the North American Spine Society does note some evidence supporting sacroiliac fusion for sacroiliac joint-mediated pain, the quality of evidence is low. Further research is recommended at this time. Therefore, the requested sacroiliac joint fusion is not likely to be more effective than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 63-year-old male enrollee has requested authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollee who has been diagnosed with acute obstructive sleep apnea. The physician reviewer found that the patient is a 63-year-old male diagnosed with obstructive sleep apnea (OSA).  He was diagnosed by a polysomnography in 2013 which indicated an apnea-hypopnea index (AHI) score of 56.5 consistent with severe OSA. The record documents failure of an extended trial of continuous positive airway pressure (CPAP) therapy.  The patient underwent septoplasty and inferior turbinate reduction on 7/1/15.   A subsequent sleep induced endoscopy indicated a palatal collapse. An uvulopalatopharyngoplasty was performed on 8/5/15.  Another polysomnography was performed on 11/24/15 which showed an AHI score of 34.5.  A follow up discussion with a provider noted options of upper airway stimulation as well as maxillo-mandibular osteotomy. The patient requests authorization and coverage for implantation of cranial nerve stimulator. The Health Insurer denied this request indicating that the requested services are investigational for treatment of this patients medical condition. The current medical literature has not shown the superior efficacy of the requested services in this clinical setting. There is a lack of independent data regarding the effectiveness of this technique when compared to available standard therapies. At this time, further outcomes data, including those regarding long term effects, are needed before it is possible to support that implantation of cranial nerve stimulator is likely to be more effective than the available standard options. While there are some studies that show the benefits of this procedure, these outcomes are documented for selected patients. These are patients who have failed CPAP therapy, who show absence of concentric airway collapse on sleep endoscopy and who are not obese.  This patient has not had a trial of CPAP therapy after having undergone nasal and palatal surgery. The documentation provided does not show that he has absence of concentric airway collapse. Lastly, he is obese based on the body mass index criteria.  Therefore, in this patients case, the implantation of a cranial nerve stimulator is not likely to be more effective than the standard options available for the treatment of this patients medical condition. 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 1

A 25-year-old female enrollee has requested reimbursement for calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that the American College of Gastroenterology guidelines for the management of Crohns disease support the use of fecal calprotectin testing, stating, In patients who have symptoms of active Crohns disease, stool testing should be performed to include fecal pathogens, Clostridium difficile testing, and may include studies that identify gut inflammation such as a fecal calprotectin. The guidelines note, Fecal calprotectin and fecal lactoferrin measurements may have an adjunctive role in monitoring disease activityStudies have shown that both fecal lactoferrin and fecal calprotectin are sensitive markers of disease activity and correlate with a number of the endoscopic activity indices. Current medical literature, including prospective trials, support fecal calprotectin to assess disease activity, assess response to treatment, and predict disease relapse in patients with inflammatory bowel disease. Various studies have found that fecal calprotectin correlates with endoscopic finding of inflammation and serum markers of inflammation in Crohns disease. The test can assess for improvement in inflammation, such as in this patient undergoing induction with Entyvio and recent disease activity at the ileocecal valve. Therefore, calprotectin fecal laboratory testing (CPT 83993) performed on 12/24/20 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 60-year-old male has requested reimbursement for gene testing provided on 11/07/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that this patient has an early stage melanoma. The National Comprehensive Cancer Network (NCCN) guidelines states 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. Thus, gene testing provided on 11/07/17 was not likely to have been more efficacious than other methods of evaluating this patient. Based upon the information set forth above, the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 38-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 11/11/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees ulcerative colitis.  The physician reviewer found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of IFX and/or the presence of antibodies to IFX may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of IFX or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Steenholdt, et al; Nanda, et al). All told, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Accordingly, the Anser IFX testing performed on 11/11/15 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: Medical Necessity
Decision: Overturned

Summary Reviewer 3 
A 30-year-old female enrollee has requested reimbursement for ultrasound and reading of the 
ultrasound on 8/2/22. The Health Insurer has denied this request and reported that the service at 
issue  was  investigational  for  the  evaluation  of  the  enrollees  pregnancy. 
The physician reviewer found that the ACOG recommends a detailed anatomy scan for all 
pregnancies, as it has been shown to detect fetal abnormalities and provide the opportunity for 
intervention or clinical decision making. Wax and colleagues note that a detailed fetal anatomic 
examination is indication driven, with indications including, but not limited to, increased risk for 
fetal anatomic or genetic abnormality. In this case, the patient had three risk factors for an abnormal 
pregnancy:  obesity,  twin  demise,  and  uterine  abnormality.  Each  one  of  these  factors  is  an 
indication alone for a detailed fetal anatomic examination.  In this clinical setting, the service at 
issue is standard medical therapy, and there was no other service that would have provided a 
similar benefit.  Therefore, ultrasound and reading of the ultrasound on 8/2/22 was likely to have 
been more beneficial for evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 33-year-old female enrollee has requested reimbursement for 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21. 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 there is sufficient support for the services at issue in this setting. If the patient had achalasia, this would be important to know. As part of revision surgery, the patient would likely undergo a myotomy of the lower esophageal sphincter, perhaps via a POEM procedure. In addition, it was important to quantify and characterize acid reflux prior to baseline in order to determine if an anti-reflux procedure such as transoral incisionless fundoplication would be needed along with revision surgery. Therefore, 91037-26 (esophageal function test, gastroesophageal reflux test with nasal catheter intraluminal impedance electrode(s) placement, recording, analysis and interpretation) performed on 7/29/21 was likely to have been more beneficial than any available standard therapy.