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

Summary Reviewer 3


A 46-year-old female enrollee has requested authorization and coverage for ketamine infusion and one day inpatient stay. The Health Insurer has denied this request indicating that the requested services are considered experimental/investigational for treatment of the enrollees peripheral neuropathy status post chemotherapy treatment. The physician reviewer found based on the documentation submitted for review, there is a lack of support demonstrating a diagnosis of complex regional pain syndrome. In addition, the current research is inconclusive in regards to ketamine for the treatment of chemotherapy induced peripheral neuropathy, which the patient does have a diagnosis (Hershman, et al; Ewertz, et al). In addition, ketamine does not help for all types of neuropathic pain and research is still ongoing (OBrien, et al). For the reasons provided, the request for inpatient ketamine infusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 58-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees cutaneous melanoma.

. The physician reviewer found that this patient is a 58-year-old male who developed malignant melanoma on the skin of left anterior shoulder with a Breslows depth of approximately 0.51 mm. The DecisionDx- Melanoma gene assay reported on 8/25/17 revealed class 1A molecular signature associated with a low risk of recurrence within five years. The patient has requested reimbursement for DecisionDx-Melanoma (laboratory service code 84999) rendered on 8/25/17.  The Health Insurer denied this request indicating that the services at issue were considered investigational for the evaluation of the patients cutaneous melanoma. 
There is a lack of peer reviewed medical literature to support the superior efficacy of the services at issue in this patients case. Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages from 0-IV. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1 consistent with a low risk of metastasis or class II suggestive of a high risk of metastasis. Sidiropoulos and colleagues noted that there was a statistically significant association of a class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently class II. The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term (within five years) metastatic disease. While DecisionDx-Melanoma signature may be an independent predictor of metastasis risk, additional studies and peer reviewed published literature are needed to show its efficacy over the available standard methods of therapy.Therefore, for the reasons stated above, the services at issue were not likely to have been 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 31-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/18/19. 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 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 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 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. All told, DecisionDx-Melanoma testing performed on 12/18/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 54-year-old female enrollee has requested authorization and coverage for panniculectomy. 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 that the submitted documentation establishes the medical necessity of the requested surgery. In this case, the patient presents with evidence of a symptomatic lower abdominal pannus in the setting of a need for repair of a ventral and incisional hernias. Her symptoms include skin breakdown over the lower aspect of the abdomen in the region of the groins and vertical scarring. In addition, the surgical plan of panniculectomy is to allow for greater exposure of the hernias for repair and to assist in the healing of the abdominal wall reconstruction, presumably by placing the incision in an area not directly overlying the hernias. Photographs support that the lower abdomen is a source of her functional issues. According to Manahan and colleagues The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. This is the case for this patient and thus, panniculectomy is medically necessary for treatment of the patients medical condition. Given the above reasons, 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 1

A 35-year-old male enrollee has requested authorization and coverage for Actemra 400 mg/ 20 ml vial. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees anti-neutrophil cytoplasmic autoantibodies (ANCA) associated crescentic and immune complex glomerulonephritis. The physician reviewer found in this clinical setting, the patients disease is advanced, thereby lowering likelihood of a significant response to treatment with the requested medication. In addition, Actemra is not U.S. Food and Drug Administration (FDA) approved for this patients diagnosis. Also, the documentation infers that the patients underlying chronic kidney disease may not be the sole cause of his progressive renal condition. Given the lack of FDA indication, combined with the low likelihood of benefit with his advanced disease, Actemra is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Based upon the information set forth above, the requested 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 44-year-old female enrollee has requested reimbursement for doxycycline capsules delayed release 40 mg received on 5/22/18. The Health Insurer has denied this request indicating that the medication at issue was not medically necessary for treatment of the enrollee, who has a history of hypersensitivity reaction affecting the periocular area. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue. The records document a hypersensitivity reaction affecting the periocular area. Per the Health Insurer, the medication at issue cannot be approved unless the patient carries a diagnosis of rosacea and has already failed a one-month course of immediate-release 50 mg doxycycline. The medication at issue, doxycycline capsules delayed release 40 mg, is not considered to be superior or more efficacious than the preferred, generic immediate-release formula of doxycycline 50 mg. In fact, given the degree of inflammation, higher doses of doxycycline would be preferred for treatment of this eruption. Thus, doxycycline capsules delayed release 40 mg received on 5/22/18 were not medically necessary for the treatment of this patient. Therefore, the medication at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 33-year-old female enrollee has requested reimbursement for the Anser IFX testing performed on 2/18/16. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees small bowel Crohns disease. The physician reviewer found the Anser IFX testing performed on 2/18/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case there was concern of an infusion reaction due to pre-formed ATI. In addition, the testing confirms that the patients symptoms were an infusion reaction and allowed for planning for subsequent infusions. Therefore, in this clinical setting the testing at issue 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: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 25-year-old male enrollee has requested reimbursement for substance abuse residential treatment services provided from 7/22/17 through 8/3/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees polysubstance and alcohol abuse. The physician reviewer found that the patients post-acute withdrawal symptoms were not severe in nature. He was not a danger to himself or others, nor was he aggressive. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. He had no comorbid medical conditions and he was psychiatrically stable. His medications could have been managed in an ambulatory setting. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He was motivated and working the program. He was cooperative and participating in his treatment plan. Although the patient continued to require further treatment to develop and solidify coping skills, this did not require the residential structure. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. Thus, as of 7/22/17, the patient no longer met the criteria for residential level of care. Accordingly, the substance abuse residential treatment services provided from 7/22/17 through 8/3/17 were not medically necessary for treatment of the patients medical condition. Based on the foregoing discussion, 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: Upheld

Summary Reviewer 2 
 
A 39-year-old female enrollee has requested authorization and coverage for cervical transection 
and avulsion of extraspinal nerve. 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 this patient has a significant history of neck pain and was 
diagnosed with cervical spondylosis. She had excellent pain relief following medial branch blocks  of the C2-C3 and C3-C4 facets bilaterally. These blocks are performed to determine if the patients 
pain is facet mediated. Standard therapy for facet mediated neck pain includes radiofrequency 
neurotomy  (ablation).  Most  high  quality  studies  for  percutaneous  cervical  medial  branch 
radiofrequency neurotomy demand at least 70% relief from medial branch blocks of a given 
cervical facet before proceeding to radiofrequency neurotomy. Duration of pain relief typically 
lasts over a year. Endoscopic rhizotomy is a more recent treatment option for facet mediated 
pain. It is typically performed in the lumbar spine. A review of the current peer-reviewed 
literature did not yield studies on cervical endoscopic rhizotomy for neck pain, let alone a study 
comparing endoscopic rhizotomy versus radiofrequency neurotomy for cervical facet mediated 
pain.  Du  and  colleagues  performed  a  comparison  study  of  endoscopic  rhizotomy  versus 
radiofrequency ablation for lumbar facet mediated pain. This study was open label (low quality) 
and both methods demonstrated significant benefit of pain relief from baseline. The endoscopic 
rhizotomy  had  slightly  better  pain  relief  when  compared  to  the  standard  radiofrequency 
neurotomy group. However, the generalizability of this study to comparing endoscopic rhizotomy 
versus radiofrequency neurotomy is not valid or reliable. The article provided by the treating 
provider is another low quality study discussing the endoscopic rhizotomy procedure for lumbar 
facet mediated pain. Given the lack of supportive peer-reviewed literature, cervical transection 
and avulsion of extraspinal nerve is not likely to be more beneficial than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old female enrollee has requested reimbursement for psychiatric residential treatment from 11/24/14 through 1/08/16.  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 the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or others.  She participated in her treatment plan.  She tolerated her medications without adverse events.  She was learning to contain herself and deal with her emotions.  Her living environment was supportive, and there was no evidence that returning her to the community would have led to a decompensation in her condition.  She had no coexisting medical conditions.  She did not require 24 hour nursing and medical supervision and although she required ongoing psychological and psychiatric treatment, this could have occurred at a lower level of care.  All told, psychiatric residential treatment from 11/24/14 through 1/08/16 was not medically indicated for the treatment of this patient.  Therefore, 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: Upheld

Summary Reviewer 1

A 64-year-old female enrollee has requested reimbursement for gene testing performed on 10/30/17. 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 FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells, with the hope that it will identify a specific mutation or target that could guide the clinician as to which chemotherapeutic agent would be useful. However, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Finding a mutation does not guarantee that a drug targeting that mutation will be beneficial. Multiple editorials have questioned the overall approach to treatment using such molecular panels. Therefore, gene testing performed on 10/30/17 was not likely to have been more effective than other available method for evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 37-year-old male enrollee has requested reimbursement and prospective authorization and coverage for assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease. The physician reviewer found that fecal calprotectin has not been definitively established for the management of Crohns disease, and may be redundant with other tests. A meta-analysis of the utility of fecal calprotectin to determine disease activity in adults with inflammatory bowel disease found poor specificity in Crohns disease (Lin, et al). In Crohns disease, studies have demonstrated that calprotectin above 150 ug/g had poor specificity (43%), and therefore poor positive predictive value in predicting relapse (Pardi and Sandborn; Costa, et al). Another meta-analysis of inflammatory bowel disease markers reported that the relatively poor specificity of fecal calprotectin in Crohns disease is a concern, as a false positive test could lead to treatment of a patient without endoscopically active disease (Mosli, et al). Use of calprotectin levels to guide therapy has not definitively been shown in controlled studies to improve clinical outcomes in patients with Crohns disease. Therefore, assay for calprotectin fecal laboratory performed on 10/28/16 and ongoing was not and is 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 and is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 38-year-old male enrollee has requested authorization and coverage for cervical disc prosthesis.  The Health Insurer has denied this request indicating that the requested services are investigational for the treatment of the enrollees medical condition.  The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  Davis and colleagues performed a prospective, randomized, controlled multicenter clinical trial on two-level symptomatic degenerative disc disease. Their findings supported the use of cervical arthroplasty at two contiguous levels and demonstrated advantages over two-level anterior cervical discectomy and fusion.  This patient presents with persistent severe neck pain radiating into the left upper extremity consistent with a C6 radiculopathy.  His symptoms are consistent with imaging and electrodiagnostic evidence of radiculopathy at C5-6 and C6-7 with plausible neural compromise.  The use of two-level artificial disc replacement will allow for motion preservation in this case.  All told, the requested cervical disc prosthesis is likely to be superior over 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of an eight-year-old male enrollee has requested reimbursement and prospective authorization and coverage for applied behavioral analysis (ABA) therapy at the frequency of 30 hours per week of H2019, 12 hours per month of H0031 and 12 hours per month of H0032 provided from 7/16/15 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 autism spectrum disorder.  The physician reviewer found the review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. The review by Reichow and colleagues shows that early intensive behavioral intervention is effective to increase IQ, improve communication and adaptive skills. In this case, there is a lack of evidence submitted for review that demonstrates the patient has made enough progress to support a reduction in services. The patient presents with maladaptive behaviors with tantrums and frequent aggression. As such, 30 hours per week of H2019, 12 hours per month of H0031 and 12 hours per month of H0032 provided from 7/16/15 forward was and is medically necessary for this patient.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 1

A 60-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/10/19. 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 this patient had an early stage melanoma. Commercially available gene expression profiling (GEP) tests are marketed as being able to classify cutaneous melanoma into separate categories based on risk of metastasis. However, it remains unclear whether these tests provide clinically actionable prognostic information when used in addition to or in comparison with known clinicopathologic factors or multivariable nomograms that incorporate patient sex, age, tumor location and thickness, ulceration, mitotic rate, lymphovascular invasion, microsatellites, and sentinel lymph node biopsy status. Furthermore, the impact of these tests on treatment outcomes or follow-up schedules has not been established. Newer prognostic molecular techniques should not replace standard staging procedures.  In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing performed on 10/10/19 was not likely to have been more beneficial than any available standard therapy.