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

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested authorization and coverage for reconstructive repair of pectus excavatum or carinatum with one overnight hospital stay.  The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition. The physician reviewer found there is sufficient support for the requested services in this patients case.  The records document pectus excavatum with a Haller index of 4.0.  This patient has a chest wall deformity, and the requested surgical repair is medically appropriate. The records support the requested correction of a congenital abnormality of the chest wall to normalize a deformity.  Pectus excavatum is a significant truncal physical variation from normal.  In sum, the requested reconstructive repair of pectus excavatum or carinatum with one overnight hospital stay is medically indicated for the treatment of this patient.  Therefore, the requested services are 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 50-year-old female enrollee has requested reimbursement for CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that bladder cancer molecular testing remains an adjunct to standard evaluation. Standard evaluation includes cystoscopy and urine cytology. Urinary biomarkers, including Cxbladder urine testing, may be useful in increasing the sensitivity of diagnosis. However, urine messenger RNA testing to detect gene expression for bladder cancer cells remains investigational at this time. Superiority of this test compared to conventional evaluation of hematuria remains to be elucidated with further studies. Recommended evaluation continues to be contrast enhanced imaging of the urinary tract and cystoscopy. In sum, CPT code 81479 (unlisted molecular pathology, Cxbladder) performed on 12/19/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 21-year-old female enrollee has requested reimbursement for the outpatient papanicolaou smear testing performed on 7/17/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees abnormal and showed atypical squamous cell of undetermined significance (ASC-US) and high risk human papilloma virus (HPV) test.   The physician reviewer found that the Pap smear performed on 7/17/15 was indicated and consistent with current guidelines for the management of an ASC-US and positive HPV Pap smear. Since the Pap smear in 2014 was abnormal, these findings required specific management planning. The ASC-US Pap smear posed a risk of representing underlying disease and needs to be clinically managed the same as a patient is in the 21-24 age category. The guidelines for management of an ASC-US and HPV positive Pap smear is to either proceed with colposcopy evaluation or to repeat the Pap smear in one year. The Pap smear done in 2015 was done as the recommended repeat study. Thus, the Pap smear performed on 7/17/15 was likely to have been 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 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 2

A 64-year-old female enrollee has requested reimbursement for genetic testing performed on 11/30/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee, who was diagnosed with breast cancer. The physician reviewer found OncotypeDX breast cancer assay uses reverse transcriptions polymerase chain reaction to assess the genomic profile by analyzing the tumor tissue with a panel of 21 genes. There is data which supports use of this assay for patients with DCIS or early stage invasive ductal adenocarcinoma to help direct care. For this patient, the report indicated a 20% risk of a recurrent event when the biopsy was examined. The surgical specimen analysis was associated with a 34% risk of recurrence of invasive disease. Studies assessing the benefit of the OncotypeDX recurrence score assay provides a prediction regarding locoregional and distant recurrence for postmenopausal women treated with tamoxifen or those treated with an aromatase inhibitor. There have also been studies that demonstrate its ability to predict response to adjuvant therapy. High scores indicated benefit from chemotherapy and low scores, regardless of lymph node involvement, did not appear to benefit. Recent data has validated the use of OncotypeDX in DCIS. It analyzes 12 genes instead of 21. The use of OncotypeDX has been validated in multiple studies but is not included in current treatment guidelines. However, in this patients clinical case, the use of OncotypeDX at two different time points helped guide the surgeon and the patient. Without the genetic testing, this patient would not have undergone mastectomy and the invasive component may not have been detected. Since current guidelines give the option of chemotherapy and Herceptin (category 2B) then the OncotypeDX performed on 11/30/16 helped direct this patients postoperative treatment plan. All told, the genetic testing performed on 11/30/16 was likely to have been more effective than the standard options for evaluation of this patients medical condition.Therefore, for the reasons stated above, the services at issue were likely to have been 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 1


A 64-year-old female has requested reimbursement for FoundationOne testing performed on 1/13/16.  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.  Molecular profiling of a patients cancer cells, as is done with FoundationOne testing, is an assay of genomic or molecular abnormalities. The goal would be to identify a target at which a specific treatment could then be offered.  At this time, there is a lack of convincing evidence that the assay adds to decision making ability in a way to significantly improve patient outcome.  There are a variety of non-randomized studies exploring the value of molecular profiling that have as yet not been convincing.  A recent randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets.  Therefore, FoundationOne testing performed on 1/13/16 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 2 
 
A 51-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 1/18/21. 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 the staging and prognosis of cutaneous melanoma is classically 
determined by applying the system spelled out by Balch. Mitotic index may add to these 
statistics. DecisionDx-Melanoma testing is an assay of 31 genes in an individuals melanoma 
cells. It then places that melanoma into either Class 1 or Class 2. It is not clear how the five-year 
DecisionDx-Melanoma data compares to the ten-year Balch data. Particularly in this case, it is 
not clear how the DecisionDx-Melanoma classification would have added clinical information to  guide further surveillance and treatment. There is a lack of data indicating whether the 
DecisionDx-Melanoma data can be used to make clinical decisions. Therefore, DecisionDx-
Melanoma testing performed on 1/18/21 was not likely to have been more beneficial than 
other available methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 39-year-old female who has a history of migraines and palpitations. The patient has requested reimbursement for laboratory testing performed on 11/12/19 and 1/17/20. 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 had a persistent thrombocytosis with a platelet count greater than 450 on three separate occasions. Iron studies are reported to be normal. It could not be determined from peripheral studies if the thrombocytosis was reactive or part of a myeloproliferative neoplasm or other neoplastic process. Molecular studies on peripheral blood were negative. Performing a bone marrow biopsy in this situation is a standard of care. Given the differential diagnosis, the services at issue are standard. The medical records support the services at issue in this clinical setting. Therefore, laboratory testing performed on 11/12/19 and 1/17/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 34-year-old male has requested reimbursement for polymerase chain reaction (PCR) testing performed on 8/03/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the EBV infection can be suspected with an appropriate clinical presentation of sore throat, fever, and malaise with enlarged lymph nodes on examination. The recommended laboratory testing for a case of EBV infection causing mononucleosis is a complete blood count and liver enzymes and heterophile antibodies. In this case, the patient presented with a recent pharyngitis and rash after treatment with an antibiotic. At the time of presentation, the patient noted improved symptoms with treatment of the antibiotic, and there was no fever or enlarged lymph nodes on examination. The concern was for EBV infection causing mononucleosis. The testing with a complete blood count was unremarkable, and the appropriate test for EBV infection would have been heterophile antibody testing.  The requested PCR would not be more beneficial in this case than the recommended testing, heterophile antibody testing. In sum, PCR testing performed on 8/03/17 was not 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 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 3


A 65-year-old male enrollee has requested reimbursement for genetic testing performed on 4/16/15.  The Health Insurer has denied this request indicating that the testing at issue was investigational for the evaluation of the enrollees medical condition.  The physician reviewer found that HLA-B5701 genetic testing is the standard of care in the treatment of HIV patients. U.S. Department of Health and Human Services (HHS) guidelines recommend HLA-B5701 genetic testing when initiating antiretroviral therapy or when considering abacavir. The test can take up to 2 to 3 weeks to obtain results so providers generally order the testing ahead of time to prevent a later delay in treatment. In addition, abacavir is a preferred regimen and is likely to be in the next selection of treatment options for this patient.  In sum, HLA-B5701 genetic testing was 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 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 40-year-old female enrollee has requested authorization and coverage for thermal destruction 
of intraosseous basivertebral nerve. The Health Insurer has denied this request indicating that 
the requested services are considered investigational for treatment of the insureds spondylosis 
without myelopathy or radiculopathy, lumbar region. The physician reviewer found that with 
regard to the request for thermal destruction of intraosseous basivertebral nerve, there is 
medical evidence supporting this treatment modality for the treatment of chronic low back pain. 
Per  Fischgrund  and  colleagues,  patients  treated  with  radiofrequency  ablation  of  the 
basivertebral nerve for chronic low back pain exhibited sustained clinical benefits in Oswestry 
Disability Index (ODI) and Visual Analog Scale (VAS) and maintained high responder rates at two 
years following treatment.  The authors concluded that, Basivertebral nerve ablation appears 
to be a durable, minimally invasive treatment for the relief of chronic low back pain. Similarly, 
Khalil and colleagues found that, minimally invasive radiofrequency ablation of the basivertebral 
nerve led to significant improvement of pain and function at 3-months in patients with chronic 
vertebrogenic related low back pain. Furthermore, Sayed and colleagues reported that, Current 
evidence supports long-term improvement in pain and function in properly selected patients for 
basivertebral nerve ablation. Within the records available for review, there is documentation of 
chronic low back pain and the patient has been diagnosed with spondylosis without myelopathy 
or radiculopathy of the lumbar region, and intervertebral disc degeneration of the lumbar region. 
The treating provider has recommended thermal destruction of intraosseous basivertebral 
nerve. The medical records indicate that the patient has exhausted conservative treatment 
including physical therapy, medication management, transforaminal epidural steroid injections, 
and  chiropractic  care.  Therefore,  the  requested  thermal  destruction  of  intraosseous 
basivertebral nerve is likely to be more beneficial for treatment of the patients medical condition 
than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The parent of a 12-year-old male enrollee has requested authorization and coverage for real-time intra-fraction target tracking for planned proton beam radiotherapy. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees craniopharyngioma status post resection.  The physician reviewer found that this patient presents with craniopharyngioma and is planned for radiation treatment. As the disease is close to optic pathway, any excessive dose to optic pathway will likely cause serious late complications. Thus, the treating provider is using real-time intra-fraction tracking as an extra precaution. This technology has been used in treatment of other tumors to make the treatment precise. Given these findings, the requested real-time intra-fraction target tracking for planned proton beam radiotherapy 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, I have determined 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 3

A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. 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 FibroTest has demonstrated that it reliably determines the presence of advanced fibrosis and cirrhosis in a variety of liver diseases which can cause continuously advancing liver injury, including hepatitis B. It is important to identify cirrhosis early, as it requires specific and routine monitoring, such as ultrasound every six months, to prevent complications. Liver biopsy, by contrast, is invasive, with risks including bleeding and bile duct injury. It is subject to interoperator variability during interpretation and is also subject to sampling error. Thus, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 42-year-old female enrollee has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational for treatment of the enrollees glioblastoma multiforme.  The physician reviewer found the patient is a 42-year-old female who is diagnosed with glioblastoma (GBM). A computed tomography (CT) of the head on 11/3/16 revealed a subtle density within the right frontal lobe. A brain magnetic resonance imaging (MRI) on 11/9/16 revealed a 1.4 x 1.1 x 1.0 cm enhancing right frontal lobe lesion. On 11/18/16, she underwent a craniotomy and resection. Pathology revealed GBM. She then received concurrent radiation and Temodar chemotherapy. Radiation was completed and she was recommended to undergo adjuvant tumor treatment fields (TTF) therapy. The patient has requested reimbursement and prospective authorization and coverage for the Optune device with transducer arrays provided from 3/8/17 forward. The Health Insurer has denied this request indicating that the equipment at issue was and is considered investigational. Optune TTF delivers alternating electric fields which disrupt mitotic activity. The device delivers electric fields via a portable device through electrodes placed on the patients scalp. TTF has been demonstrated to be an effective treatment for this patients disease, which is a disease in which few treatments have ever shown efficacy outside of standard surgery and radiation. It should be recognized that for TTF fields, the randomized data are from large multi-institutional studies by providers who specialize in the treatment of GBM. Thus, compared to other options, the Optune device with transducer arrays provided from 3/8/17 forward was and 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 equipment at issue was and 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 40-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/08/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts were described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures better enables the possibility of demonstrating an otherwise occult tumor.  Thus, digital breast tomosynthesis performed on 9/08/16 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 64-year-old male insured has requested reimbursement for laboratory testing performed on 
5/13/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds acute deep vein thrombosis (DVT). The 
physician reviewer found that current guidelines from the American College of Chest Physicians 
(ACCP) recommend treatment with extended duration anticoagulation after unprovoked venous 
thromboembolism unless the risk of bleeding is high or is contrary to the patients values and 
preferences (Palareti, et al.). In addition, a recent meta-analysis included 24 studies summarizing 
13,571 patients, of which heterozygous Factor V Leiden mutation was identified in 2,840 patients 
(Eppenberger, et al.). The authors concluded that against the background of established risk 
factors, the Factor V Leiden mutation plays only a marginal role in the risk assessment for 
recurrent venous thromboembolism and does not change anticoagulation management. As in 
this patients case, the hypercoagulable work-up for Factor V Leiden and Prothrombin G20210A 
gene mutation was not recommended in the setting of an unprovoked venous thromboembolism 
as it only confers a marginal risk compared to other known factors and does not change 
anticoagulation management. Therefore, the laboratory testing performed on 5/13/22 was not 
likely to be more beneficial for evaluation of the patients medical condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 64-year-old female enrollee has requested authorization and coverage for Kadian 50 mg three times per day. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees neck and bilateral shoulder pain. The physician reviewer found that in this case, the request for Kadian 50 mg three times per day is medically necessary and reasonable for management of this patients medical condition. The patient has post-laminectomy syndrome with ongoing chronic pain. The patient previously had an intrathecal pain pump which was removed secondary to meningitis. The patient has been maintained on Kadian 50 mg three times per day for over 10 years with appropriate monitoring and safeguards in place. The records document that Kadian 50 mg three times per day keeps her active and allows her to participate in her activities of daily living. All told, the requested Kadian 50 mg three times per day is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.