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

Summary Reviewer 2

A 58-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Gene Assay has shown some accuracy in thin melanomas. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. However, when an SNLB is negative there is a no accounting for hematologic spread and the Class 2 results suggest there must be another type of spread other than lymphatic which is the only type of spread accounted for by the NCCN guidelines. In this case, the patient would benefit from close follow-up clinically with ultrasound and computed tomography (CT), since he is Class 2. Thus, the DecisionDx-Melanoma Gene Assay was likely to provide additional useful information in evaluating and treating this patient. All told, the DecisionDx-Melanoma Gene Assay testing provided on 4/24/17 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 3

A 47-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/24/15. 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 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. In this clinical setting, a breast tomosynthesis would be valuable in determining whether an area of asymmetry warrants a biopsy. However, the standard modalities would be more beneficial as the interpreting radiologist requested the old studies. There is always considerable variability in the appearance of breasts, and the most valuable tool is for the radiologist to compare the current study in question with old mammograms. In this case, the tomosynthesis provided 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

An 18-year-old male enrollee has requested reimbursement for mental health partial hospitalization provided from 1/23/18 through 1/31/18 and 2/07/18 through 2/20/18 and intensive outpatient program services provided from 2/21/18 through 3/20/18. 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 in sum, intensive outpatient program services provided from 2/21/18 through 3/20/18 were medically necessary for the treatment of this patient. The submitted documentation fails to demonstrate the medical necessity of mental health partial hospitalization provided from 1/23/18 through 1/31/18 and 2/07/18 through 2/20/18.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 15-year-old female enrollee has requested reimbursement for inpatient care from 4/13/17 through 4/19/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The medical records indicate that this patient continued to exhibit the same acuity level of thoughts of self-harm and suicide that were the reason for her admission.  Transfer to residential treatment center level of care was not an option as the residential treatment center professionals felt she was still too acute and not ready for this transfer.  Based on the records, continued treatment at the inpatient level of care was indicated.  Her history shows that a premature discharge would result in a quick relapse and readmission.  All told, inpatient care from 4/13/17 through 4/19/17 was medically necessary for the treatment of this patient. Therefore, the services at issue were 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 49-year-old female enrollee has requested reimbursement for laboratory services performed 
at Diagnostic Solutions Laboratory on 3/29/22. The Health Insurer has denied this request and 
reported that the services at issue were investigational for the evaluation of the enrollee. The 
physician reviewer found that while there has been some investigation into the link between the 
gut microbiome and gastrointestinal health and disease, there are no formal or scientifically 
sound clinical trials evaluating microbiome testing and its utility in the workup and management 
of irritable bowel syndrome. While Tap and colleagues note in an observational study that certain 
microbiome profiles can help predict the severity of symptoms in irritable bowel syndrome, this 
knowledge would not necessarily change the workup and management of the condition. In a 
similar observation study, Zhu and colleagues found that patients with irritable bowel syndrome 
had a significantly differential metabolite profile as compared to healthy controls, but again, such 
information does not affect the manner in which irritable bowel syndrome would be tested for 
or managed. There are no available studies for review that have investigated the general benefit 
of comprehensive gastrointestinal mapping or its benefit over standard testing in the workup and  management of irritable bowel syndrome. Notes dated 6/6/22 reported diagnoses of irritable 
bowel syndrome with constipation and noted that the patients predominant symptoms were 
constipation and bloating. The records noted that gastrointestinal mapping revealed detectable 
Clostridium difficile toxin and elevated anti-Gliadin IgA levels. In this clinical setting, the positive 
Clostridium difficile toxin that was identified in the gastrointestinal mapping could have been 
identified through standard, widely available, focused stool testing. Further, the elevated anti-
Gliadin IgA could have been evaluated for with standard serum testing for celiac serologies. 
Therefore, laboratory services performed at Diagnostic Solutions Laboratory on 3/29/22 were 
not likely to have been more beneficial for evaluation of the patients condition than any available 
standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 52-year-old male who had a history of a stage IIB (T4N0) colon adenocarcinoma diagnosed in 2017. He was treated with adjuvant chemotherapy and was noted to have no mutations. The physician reviewer found that as a standard of care, metastatic colon cancers should be tested for KRAS, NRAS, BRAF, HER2, and microsatellite instability (MSI) or mismatch repair (MMR) testing. Per the National Comprehensive Cancer Network guidelines, these can be done individually or as part of next-generation sequencing (NGS). NGS panels have the ability to pick up rare and actionable mutations and fusions. Universal genetic testing is recommended on all colon cancer tumors, and NGS allows for initial screening with MSI testing. NGS offers the advantage of identifying markers known to have targeted therapy as well as potential clinical trials. This patient has metastatic colon cancer that is recurrent. Although his initial tumor did not have any mutations, the panel has expanded since he was diagnosed, and recurrences can develop new mutations. The
medical evidence supports the services at issue in this clinical setting. Therefore, CPT codes 81202, 91275, 81292, 81298, 81301, 81311, 81321, 81404, 81406 XU x 2 and 81479 XU x 4 performed on 5/12/19 were medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/7/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees breast cancer examination.  The physician reviewer found that the Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In addition, there was identified a questionable mass, and tomosynthesis will often better localize, confirm, and characterize a mass. Accordingly, the digital breast tomosynthesis performed on 10/7/16 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 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 47-year-old female enrollee has requested reimbursement for the breast tomosynthesis performed on 4/24/15. 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 that there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis. The authors concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram is due to improved cancer detection rate.  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: Medical Necessity
Decision: Overturned

Summary Reviewer  
 
The patient is a 66-year-old male who has a history of hyperlipidemia and moderate coronary 
disease. The patient has requested authorization and coverage for Vascepa (icosapent ethyl 
capsule 1 gm). The patients parent has requested authorization and coverage for Norditropin 
(somatropin) 10 mg in 1.5 ml. The physician reviewer found that in the REDUCE-IT trial, Vascepa 
was  shown  to  be  superior  to  placebo  in  reducing  triglycerides,  cardiovascular events  and 
cardiovascular death among patients with high triglycerides and either known cardiovascular 
disease or patients with diabetes plus significant cardiovascular risk factors. This patient has 
significant cardiovascular disease with documented coronary atherosclerosis. The submitted 
documentation  included  laboratory  testing  from  2003,  2007  and  2008.  These  records 
documented  elevated  triglyceride  levels.  Vascepa  is  indicated  for  elevated  triglycerides  in 
patients  with  cardiovascular  disease  or  diabetics  with  cardiovascular  risk  factors.  There  is 
sufficient support for the requested medication in this clinical setting.  Therefore, Vascepa 
(icosapent ethyl capsule 1 gm) is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 43-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 2/14/18. 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 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 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 2/14/18 was not 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 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 

The patient is a 40-year-old transgender female who is seeking facial feminization surgery. Per the Health Insurer, the requested services are not medically necessary for the treatment of the patientas medical condition. The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Facial feminization surgery is a common treatment for gender dysphoria. Ainsworth and Spiegel demonstrated that facial feminization surgery, like genital surgery, aimproved mental health-related quality of life.a The World Professional Association for Transgender Health (WPATH) Position Statement on Medical Necessity of Treatment states, aNon-genital surgical proceduresa notably facial feminization surgeryaare often of greater practical significance in the patientas daily life than reconstruction of the genitalsaThese reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition.a Therefore, the requested facial feminization surgery is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a one-year-old male enrollee has requested reimbursement for inpatient hospital level of care provided on 3/31/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees gastroesophageal reflux disease (GERD).  The physician reviewer found the patient was a five-month-old ex-premature infant who was approximately 44 weeks post conceptual age at the time that he presented for apnea and cyanosis associated with vomiting for which he was treated with back blows by his mother. The apneic episode resolved by the time of presentation to the hospital and he appeared to be healthy when evaluated by the provider. He was admitted for observation and cardiopulmonary monitoring. He was diagnosed with an apparent life threatening event (ALTE) due to gastroesophageal reflux disease (GERD). Other than monitoring, he received a suppository to treat constipation. He had no further apnea or cyanosis in the hospital. He tolerated oral intake without emesis. He remained well appearing and had no signs of acute illness. The medical literature supports hospitalization for observation for cardiopulmonary monitoring for 23 hours after an ALTE in the majority of infants (Fu and Moon; McGovern and Smith). However, certain individuals can be discharged from the emergency department without hospitalization (Kahn and European Society for the Study and Prevention of Infant Death). Given that the patient was well-appearing at the time of presentation, had no further events during observation in the hospital, did not require specific interventions or extensive evaluation beyond observation, and was discharged home on the same day of admission, he met criteria for observation but not admission. Based upon the information provided and reviewed and the medical literature reviewed, the inpatient hospital level of care provided on 3/31/16 was not medically necessary for treatment of the patients medical condition. For the reasons provided, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that there is evidence-based support for this procedure. In this case, the patient has chronic low back pain that has not responded to at least six months of conservative care. The patient has had multiple treatments, including lumbar epidural steroid injections, medial branch blocks, aquatic therapy, massage therapy, home exercise program, stretching, cryotherapy, transforaminal epidural steroid injection, chiropractic manipulation and medication management. There are also Type II Modic changes in the lumbar spine at the L3-4 and L4-5 levels. There is sufficient evidence-based support for the requested services. There has been sufficient, documented, detailed, comprehensive and reasonable treatment provided prior to this request. Therefore, the requested spine procedure is likely to be more beneficial for the treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 27-year-old female enrollee has requested reimbursement for genetic testing including methylenetetrahydrofolate reductase (MTHFR) gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for bleeding disorder.  
 
 The physician reviewer found that there is a lack of large well defined studies that support the superiority of the services at issue when compared to the available standard options of evaluating this patient.  A January 2011 guideline from the Evaluation of Genomic Applications in Practice and Prevention (EGAPP) Working Group recommends against routine testing for factor V Leiden and/or the prothrombin 20210 mutation in asymptomatic family members of patients with venous thromboembolism. In this patients case, the genetic testing would not have provided a greater value in the assessment of this patients condition over the standard options available. As such, genetic testing including MTHFR gene analysis, common variants, and factor V Leiden mutation testing provided on 7/1/17 was not likely to have been superior over any of the available standard methods of evaluating this patient.

Based upon the information set forth above, the services at issue were 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 53-year-old female enrollee has requested authorization and coverage for foam sclerosant/endovenous ablation. 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 the submitted documentation supports a portion of the requested services. The records noted a plan for a large number of procedures, each performed on isolated days. No medical reason for performing each procedure on isolated days is documented. These procedures have been requested without documentation of a plan to reassess the patient after initial procedures.  However, there is documentation of symptomatology that is impacting this patients daily activities despite the use of compression stockings. There is documentation of truncal superficial venous reflux as well as absence of deep vein thrombosis in the presence of palpable pedal pulses. Therefore, the documentation supports bilateral greater saphenous vein ablation and one session of sclerotherapy per leg, although the truncal ablation and sclerotherapy for each leg should be performed on the same day. The records support a total of two days of service (one day for each leg). Anything performed after the first of service for each leg would require clear documentation of failure of the approved procedures to improve symptomatology with documentation of continued activity limiting symptoms despite the regular use of compression stockings. In sum, bilateral greater saphenous vein ablation and one session of sclerotherapy per leg are likely to be superior over other available treatment options.