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

Summary Reviewer 1 
 
An  83-year-old  male  enrollee  has  requested  reimbursement  for  Guardant360  CDx  testing 
performed on 3/31/21. The Health Insurer has denied this request and reported that the services 
at issue were investigational for the evaluation of the enrollees medical condition. The physician 
reviewer  found  that  molecular  diagnostic  studies  in  non-small  cell  lung  cancer  (NSCLC)  are 
considered a standard of care. Numerous gene alterations have been identified that impact 
therapy selection. The National Comprehensive Cancer Network (NCCN) NSCLC Guidelines Panel 
strongly advises broader molecular profiling with the goal of identifying rare driver mutations for 
which effective drugs may already be available, or to appropriately counsel patients regarding 
the availability of clinical trials. Broad molecular profiling is a key component of the improvement 
of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important 
for identification of potentially efficacious targeted therapies, as well as avoidance of therapies 
unlikely to provide clinical benefit. Integration of plasma next-generation sequencing testing into 
the routine management of stage IV NSCLC demonstrates a marked increase of the detection of 
therapeutically targetable mutations and improved delivery of molecularly guided therapy. 
Therefore, Guardant360 CDx testing performed on 3/31/21 was likely to have been more 
beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 53-year-old female enrollee has requested reimbursement for OVA1 testing performed on 5/19/15. 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 submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Biomarkers such as OVA1 are imprecise and are not specific enough to be accurately used for ovarian cancer screening.  Therefore, its utility in a clinical setting is limited.  This patient had an ovarian cyst, which was simple in nature and decreasing in size.  Both of these features are not associated with neoplasm.  In this case, the medical evidence does not support screening with OVA1 testing was due to the high risk of false positives leading to unnecessary testing and invasive procedures.  Therefore, OVA1 testing performed on 5/19/15 was not likely to have been of greater benefit than other modalities.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 27-year-old transgender female enrollee has requested reimbursement for breast augmentation surgery performed on 6/13/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting. The records document gender dysphoria. The patient has been prescribed hormone therapy since February 2018, and she continued to experience severe dysphoria related to her chest. The World Professional Association for Transgender Health (WPATH) supports augmentation mammoplasty for the treatment of gender dysphoria. The WPATH position statement noted that breast augmentation...is often of greater practical significance in the patients daily life than genital surgery. The current medical evidence supports the services at issue in this clinical setting. Therefore, breast augmentation performed on 6/13/19 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for inpatient mental health treatment from 2/8/17 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient was admitted to an inpatient unit in mid-November 2016.  The patients stay was approximately three months prior to the Health Insurers denial. The progress notes reflect variable behaviors on the part of the patient. It appears that he has days where he exhibits self-injurious behaviors and days where he is calm and cooperative.  However, the progress notes do not reflect a drastic change or improvement in his behavior. He continues to have issues with nonadherence to his medication regimen. The treatment goals listed by the inpatient team appear to be more of long-term goals and include generalization of skills. It is unlikely that generalization of learned skills would occur in an inpatient environment, as this environment is artificial and not indicative of any home type environment.  It is also not clear that continued inpatient care would result in increased adherence to medications, as the patient appears to almost randomly refuse medications. The standard practice in this clinical setting is to utilize an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) when determining the necessary level of care for children. This system provides a tool that would ensure that a patients level of care meets their individual needs at the least restrictive setting possible. The American Academy of Child and Adolescent Psychiatry always recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports (Winters).  There was a lack of medical information provided to indicate that this patient could not have been treated in a less restrictive setting.  According to the submitted documentation, continued inpatient care is not the least restrictive environment for this patient. As such, inpatient mental health treatment for 2/8/17 forward were not and are not medically necessary. Therefore, for the reasons stated above, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 26-year-old male with a history of suspected multiple sclerosis (MS). In an effort 
to treat the patients flare and as maintenance therapy for suspected MS, the provider has 
recommended treatment with intravenous immunoglobulin (IVIG) therapy with Gamunex-C. The 
Health Insurer has denied the requested treatment as not medically necessary for the treatment 
of the patients medical condition. The physician reviewer found that the records provided for 
review indicate that the patient experienced an exacerbation of symptoms from suspected MS. 
For patients who experience an acute MS exacerbation that results in neurologic symptoms and 
increased disability or impairments in vision, strength, or cerebellar function, a short course of 
high-dose glucocorticoid therapy is recommended (Olek, et al.). If the patient has a poor response 
to treatment with high-dose glucocorticoids, treatment with plasma exchange is considered for 
the next line of therapy. Other options for a second treatment course after a poor response to 
initial high-dose glucocorticoid therapy include adrenocorticotropic hormone (ACTH), a second 
cycle of high-dose glucocorticoid therapy, or immunoadsorption. There is a paucity of high-
quality medical studies demonstrating that IVIG therapy is an effective treatment option for 
patients who experience an exacerbation of symptoms from suspected MS. A small number of 
limited medical studies have demonstrated that IVIG therapy may be used for patients with 
relapsing-remitting MS who do not tolerate or have contraindications to approved therapies 
(Bayry, et al.). In this case, a diagnosis of relapsing-remitting MS has not been established for the 
patient. The records indicate that the patient experienced an acute exacerbation of symptoms 
from suspected MS. Based on the current medical literature, IVIG therapy is not recommended 
as a treatment option for patients with acute exacerbations of symptoms from suspected MS. 
Therefore, the requested Gamunex-C is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 61-year-old male enrollee has requested reimbursement for the Life Vest provided on 5/23/14. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees congestive heart failure and atrial fibrillation.  The physician reviewer found that the review of currently available peer-reviewed literature does support the safety and efficacy of wearable cardioverter defibrillators (WCD) in this clinical setting. Chung and colleagues demonstrated low sudden cardiac death in patients at increased risk with WCD comparable to implantable cardioverter defibrillator (ICD) patients. However, Adler and colleagues indicated that when a wearable defibrillator is considered, there are no randomized, controlled studies showing that it provides survival benefit compared to standard alternatives. WCD is currently indicated for patients who have met medical necessity criteria for ICD deployment and are awaiting cardiac transplantation and have met criteria for cardiac transplantation, have had a previously implanted ICD explanted due to an infection and are awaiting ICD re-implantation, or have an infectious process or other temporary condition that would preclude initial implantation of an ICD. In this case, the WCD was deployed five days after the initial diagnosis was made and the patient did experience a return to normal LV function. All told, the Life Vest provided on 5/23/14 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 17-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy provided from 2/23/17 through 8/23/17. 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 autism spectrum disorder. The physician reviewer found that Brosnan and Healy indicate that ABA therapy is an effective treatment to reduce aggressive behavior in individuals with autism spectrum disorder. Hanley and colleagues also report that ABA is highly effective in reducing problematic behaviors. According to the documentation submitted for review, the patient engages behaviors that pose a danger to himself and others, particularly his aggressive and injurious behavior, and his behavior when traveling in a car. There are several areas in which the patient has made no progress during the last authorization period, including the areas of social, play and cognition, adaptive/motor skills, and executive function. ABA therapy at the providers recommended frequency are medically necessary to address the patients behavioral challenges is clinically indicated for this patient. Therefore, the request for 20 hours per week of direct ABA therapy, eight hours per month of supervision, two hours per month for treatment planning and two hours per month for parent training provided from 2/23/17 through 8/23/17 were and are medically necessary for treatment of the patients medical condition. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 56-year-old male enrollee has requested reimbursement for DecisionDX-Melanoma test performed on 8/4/15.  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 the medical studies have shown 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 they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. In this patients case, a sample of his tumor was sent for DecisionDX-Melanoma testing. However, there is very little data on the DecisionDX-Melanoma test. The available studies are unclear as to how to incorporate this assay into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the National Comprehensive Cancer Network guidelines. As such, the medical data available does not support the superior efficacy of DecisionDX-Melanoma, performed on 8/4/15, over other standard methods of staging for the evaluation of this patients tumor.  Therefore, for the reasons stated 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 2

The patient is a 63-year-old male with benign prostatic hyperplasia (BPH). He was having symptoms of frequency, dysuria and intermittent stream. His prostate specific antigen (PSA) was elevated at 10. On 8/3/17, a computed tomography (CT) of the abdomen and pelvis showed a large prostate, thickened bladder and a bladder stones.  On 8/24/17, he had a transrectal ultrasound and magnetic resonance imaging (MRI) of the prostate, a prostate biopsy, cystoscopy and cystolitholapaxy. The biopsy was negative for prostate cancer. The patient has requested authorization and coverage for a prostatic urethral lift implant. The Health Plan has denied this request indicating that the requested surgical procedure is considered investigational. The UroLift procedure can provide advantages over the tradition transurethral ultrasound resection of the prostate (TURP) for an obstructing prostate causing lower urinary tract symptoms. The UroLift can be done as an outpatient, with no significant blood loss, minimal anesthesia and no catheter afterwards. Given this support, the requested prostatic urethral lift implant 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 procedure 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 Reviewer 


A 53-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the bilateral breasts. The Health Insurer has denied this request indicating that the requested diagnostic procedure is not medically necessary for evaluation of the enrollees risk of breast cancer. The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested diagnostic procedure. According to Phi and colleagues, the Addition of MRI to mammography for screening BRCA1/2 mutation carriers age greater than 50 years improves screening sensitivity by a magnitude similar to that observed in younger women. Limiting screening MRI in BRCA1/2 carriers age greater than 50 years should be reconsidered. In addition, Warner and colleagues state Screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer. The medical literature supports the use of breast MRI for women with higher risk of breast cancer, such as women with BRCA mutation. Given that the patient is less than a month away from her annual breast MRI screening and this is also to be used for pre-surgical mastectomy evaluation, it is medically necessary for this patient to have a screening breast MRI a few weeks earlier. For the reasons provided, the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for blood test (protein biomarker tests or 4Kscore) provided on 10/29/18. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for developing metastases. The physician reviewer found that this patient had a negative biopsy. The 4Kscore test may be useful when there is persistent prostate-specific antigen (PSA) elevation. In this case, the records do not document persistent PSA elevation. Furthermore, 4Kscore testing may be beneficial in the prognosis of prostate cancer and its aggressiveness. The medical evidence has not demonstrated that the services at issue were likely to have been of greater benefit than standard prostate cancer screening tests in this patients case. In sum, the blood test (protein biomarker tests or 4Kscore) performed on 10/29/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 39-year-old male enrollee has requested reimbursement for the surgery performed on 9/22/15. The Health Insurer has denied this request indicating that the surgery at issue was considered investigational for treatment of the enrollees degenerative disc disease (DDD) with herniations.  The physician reviewer found the medical records indicate that the patient has chronic back pain and multiple levels of lumbar degeneration. Two-level artificial disc replacement surgery remains experimental. The procedure is U.S. Food and Drug Administration (FDA) approved for only single level use. Outcomes and complications of two-level total disc replacement surgery remain unknown this time. More research is needed to confirm preliminary findings to determine whether the procedure has a role in treating patients with two-level disc disease. All told, there is inadequate data to support the surgery performed on 9/22/15 as likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, the surgery at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 51-year-old female who had a vaginal delivery in 2004 complicated by grade 4 episiotomy and Clostridium difficile on and off for six months. The patient has requested reimbursement for opium tincture 10 mg/mL provided on 2/18/20. The Health Insurer has denied this request and reported that the medication at issue was not medically necessary for the treatment of this patient. The physician reviewer found that the use of opium tincture is supported as medically necessary for the treatment of this patientas incontinence and diarrhea. American Society of Colon and Rectal Surgeons guidelines for the treatment of fecal incontinence state that medical management should be first-line therapy, and opioids result in decreased intestinal motility, decreased intestinal secretion, and increased absorption. Opiates are recommended as safe and effective for the treatment of chronic diarrhea. The patient has been stabilized on opium tincture for several years. She has attempted several medical alternatives and has undergone sacral nerve stimulator. There is sufficient support for the requested medication in this setting. Therefore, opium tincture 10 mg/mL provided on 2/18/20 was medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 63-year-old female who presented to her provider on 4/30/20. The patient has requested authorization and coverage for surgery of the left shoulder. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that Osteoarthritis of the acromioclavicular joint is a frequent cause of shoulder pain and can result in significant disability. Although the treatment is usually conservative, surgery may be necessary if conservative treatment is not effective and there is documented severe pathology and the pain source can be confirmed. In this case, there is a history of pain, failed conservative treatment, large osteophytes on the MRI scan, clinical evidence of localized tenderness over the acromioclavicular joint, and evidence of a type 2 acromion with impingement syndrome. Conservative treatment for impingement syndrome has also not been effective. This patient meets the criteria for surgical management of the persistent acromioclavicular joint arthritis. Additionally, she also has failed conservative management of anterior shoulder impingement for six months and there is evidence of a type 2 acromion and narrowed supraspinatus outlet. Therefore, the requested surgery of the left shoulder is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 49-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 1/11/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that the records indicate this patient was on Humira but appeared to be non-responsive. Determining therapeutic levels with the Anser ADA test with no antibodies can provide a valuable medical guide to the treating provider. As noted in the medical literature, the Anser ADA test measures the Humira blood level and detects antibodies to Humira (Ordas, et al). A patient with detectable levels and no antibodies will likely require a change in treatment management in order to control their disease, as the test potentially implies an escape phenomenon to Humira (Afif, et al). Patients with undetectable levels and low/no antibodies are under-dosed and a higher dose will be needed to achieve remission and control of disease (Baert, et al). Patients with a low level and detectable antibodies have a low drug level due to the development of antibodies. In this case, the patient was found to have detectable levels and no antibodies and was switched to Remicade. In this clinical setting, the use of the Anser ADA test performed on 1/11/16 was likely to have been more beneficial for evaluation and treatment of this patients Crohns disease than standard available testing. Based upon the information set forth above, the testing 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.