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

Summary Reviewer 1 
 
A 44-year-old male enrollee has requested reimbursement for nasopharyngoscopy, surgical, with 
dilation of eustachian tube (i.e. balloon dilation); bilateral on 7/6/21. The Health Insurer has denied 
this request and reported that the service at issue was investigational for the treatment of the 
enrollees bilateral chronic eustachian tube dysfunction. The physician reviewer found that the Anand 
and colleagues report that balloon eustachian tuboplasty shows efficacy at a follow-up of one year 
with  the  combination  of  balloon  dilation  and  medical  management  resulting  in  improved 
eustachian tube dysfunction symptoms versus medical management alone. In this case, the patient 
had a history of ear pressure and had undergone bilateral myringotomy with tube placement 
without improvement. A balloon eustachian tuboplasty resolved his symptoms. In this clinical 
setting, the balloon eustachian tuboplasty, which provides long-term relief, was likely to have been 
more  beneficial  than  standard  therapies  that  only  provide  short-term  relief.  Therefore, 
nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e. balloon dilation); bilateral on 
7/6/21 was likely to have been more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 29-year-old female enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19. 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 per the literature, immunoglobulin G (IgG) food sensitivity testing is not considered a clinically useful, relevant, or valid method for evaluating for food allergy, or for identifying food intolerance that may be contributing to gastrointestinal disease or any other condition. IgG and IgG subclass antibody tests for food allergy-related conditions do not have clinical relevance, are not validated and lack sufficient quality control. IgG signifies exposure to a food, not allergy to a food. IgG antibodies to food are commonly detectable in healthy individuals, independent of the presence or absence of food-related symptoms. Since a normal immune system should make IgG antibodies to foreign proteins, a positive IgG test to a food is a sign of a normal immune system. IgG4 against foods indicates that the organism has been repeatedly exposed to food components, recognized as foreign proteins by the immune system. Its presence should not be considered as a factor that induces hypersensitivity, but rather as an indicator for immunological tolerance, linked to the activity of regulatory T cells. At present, there is a lack of reliable and validated clinical tests for the diagnosis of food intolerance. IgG testing lacks both a sound scientific rationale and evidence of effectiveness. The lack of correlation between results and actual symptoms, and the risks resulting from unnecessary food avoidance, escalate the potential for harm from this test. Further, there is a lack of published clinical evidence to support the use of IgG tests to determine the need for vitamins or supplements or dietary modifications. In sum, allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
 
The patient is a 57-year-old female who previously submitted a request for an 
independent medical review (IMR) for reimbursement for positron emission 
tomography (PET) scan with computed tomography (CT) for attenuation performed 
on 3/02/20 and 9/01/20.  The physician reviewer found that the letter 
requesting a re-review cited the policy of the NIA, which describes 
aSubsequent Treatment Strategy (Indications for an Oncological FDG PET 
SCAN).a(cid:157)  However, the complete quote from the NIA guidelines was not noted 
in the letter of appeal. Specifically, the complete quote from the NIA 
guidelines states, aRestaging or monitoring response to active treatment, 
and/or a single evaluation after completion/cessation of therapy not to be 
performed within four weeks of completion of therapy (ideally FDG PET is 
delayed two to three months after surgical therapy, two to three months after 
radiation therapy if locoregional assessment is the imaging goal), and/or 
evaluation for suspicion of recurrence due to new or changing signs/symptoms. 
(Asymptomatic surveillance is not approvable) (NCCN, 2018).a(cid:157) Thus, the NIA 
guidelines are in agreement with the NCCN guidelines that state that 
asymptomatic surveillance is not approvable. Therefore, the additional 
documentation does not change the original IMR determination. The requested 
PET scan with CT for attenuation performed on 9/01/20 was not medically 
necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The patient is a 58-year-old male with prostate cancer. He presented with an elevated prostate-specific antigen (PSA) level of 5. He had core biopsies performed where 3 of 14 cores were positive for prostate adenocarcinoma, Gleason score 3+3=6. The patient has requested reimbursement for Oncotype DX Prostate Assay performed on 9/29/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  Once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities, because many patients will not require therapy and may be followed closely instead. The important features to recognize are Gleason score and PSA, but these are imperfect. Thus, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX Prostate Assay is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). The GPS identifies patients that had very low risk disease that could be followed rather than referred for surgery. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Thus, the Oncotype DX Prostate Assay is medically appropriate in this context. All told, Oncotype DX Prostate Assay performed on 9/29/17 was likely to be superior over other available methods of evaluating this patient. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 68-year-old female enrollee has requested reimbursement for human epididymis protein 4 (HE4) testing performed on 9/20/18. 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 there is a lack of support for the services at issue in this clinical setting. In patients with endometrial cancer, human epididymis protein 4 (HE4) has been described as a potential marker for deep myometrial invasion and for advanced-stage disease. However, the sensitivity and specificity is not well-documented, and normal values are still being delineated. Routine testing is not considered a standard of care for surveillance and is unlikely to change outcomes in determining recurrence of disease. In sum, HE4 testing performed on 9/20/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 57-year-old female enrollee has requested authorization and coverage for biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission. The Health Insurer has denied this request indicating that requested services are considered investigational for treatment of the enrollee, who has a history of morbid obesity and type 2 diabetes.The physician reviewer found that in patients who seek surgical cure or amelioration of diabetes and obesity, several options exist.  Among these options are laparoscopic sleeve gastrectomy, which this patient had undergone.  The medical studies indicated that sleeve gastrectomy was first offered as the first part of a two-stage biliopancreatic diversion for patients who were super-obese, and are felt to be poor surgical candidates. It was then that it was realized that sleeve gastrectomy could stand on its own as a bariatric surgery. Nevertheless, there is a group of patients for whom sleeve gastrectomy fails to effect good glycemic control, as in this patients case. For these patients, the best remaining surgical solution is conversion of biliopancreatic bypass. Biliopancreatic bypass with duodenal switch is documented to be superior to medical management for treatment of weight loss. As such, biliopancreatic bypass with duodenal switch (CPT code 43845) and one day inpatient admission are likely to be more effective than the other available options for the treatment of this patient. 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 

This patient is a 45-year-old male with history of major depressive disorder. The patient has requested reimbursement and prospective authorization and coverage for transcranial magnetic stimulation provided from 8/12/20 forward. The Health Insurer has denied this request and reported that the services at issue were not and are not medically necessary for the treatment of this patient. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has had prior trials of two antidepressants. He has also been in weekly CBT since 2015, and this has also been ineffective. For patients with major depression that does not respond to initial treatment with an antidepressant and who decide to switch treatment, another reasonable option is repetitive transcranial magnetic stimulation. Meta-analysis of randomized trials that compared transcranial magnetic stimulation with sham treatment indicate that transcranial magnetic stimulation can be efficacious for acute treatment-resistant depression. Repetitive transcranial magnetic stimulation is indicated for patients with unipolar depression who have failed at least one antidepressant medication. Use of repetitive transcranial magnetic stimulation for treatment-resistant depression is consistent with treatment guidelines from the American Psychiatric Association. Therefore, transcranial magnetic stimulation provided from 8/12/20 forward was and is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 57-year-old male with a history of oligometastatic adenocarcinoma of his prostate gland. The patient has requested authorization and coverage for intensity modulated radiation therapy image-guided radiation. 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 the requested services are standard of care in this clinical setting. High-quality clinical outcomes published in the peer-reviewed medical literature have proven that aggressive consolidation of oligometastatic prostate cancer is associated with a significant improvement in chances for long-term survival. The high-quality prospective trial by Parker and colleagues supports such a benefit, as definitive radiotherapy improved failure-free survival. IMRT is widely employed nationwide for similar patients in this setting. Therefore, intensity modulated radiation therapy image-guided radiation is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 62-year-old male enrollee has requested reimbursement for laboratory services provided on 9/06/18. 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 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 the DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has 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, laboratory services provided on 9/06/18 were not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 41-year-old female enrollee has requested reimbursement for Cymetra micronized AlloDerm tissue provided on 2/13/15. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees left vocal fold paresis status post excision of vagal nerve schwannoma.  The physician reviewer found there are many different types of injectable material used for augmentation of a paralyzed vocal cord. Cymetra micronized AlloDerm injectable tissue is a widely utilized material for use in this clinical setting. It has low risk of infectious transmission, but is otherwise medically indicated and accepted as part of standard care in the otolaryngologic community. All told, the Cymetra micronized AlloDerm tissue provided on 2/13/15 was medically necessary for treatment of this patients left vagal nerve schwannoma with resultant left vocal cord paresis. In conclusion, 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 28-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the Anser ADA testing performed on 12/1/15 is not supported by the documentation submitted for review. In this case, the patients Crohns was responsive to Humira, but she developed a rash of uncertain origin for which the Prometheus Anser assay was ordered. It has not yet been established in the peer-reviewed literature whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Generally, diminished or suboptimal response to adalimumab can be managed by shortening the interval between doses, increasing the dose, switching to a different anti-TNF agent or switching to a non-anti-tumor necrosis factor agent based on clinical observation in lieu of Anser testing. For the reasons provided, the Anser ADA testing performed on 12/1/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 16-year-old male enrollee has requested reimbursement for the residential treatment services provided from 4/28/14 through 6/21/14. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees anxiety and attention deficit hyperactivity disorder (ADHD). The physician reviewer found that the records provided for review do not support the medical necessity of the residential treatment services provided from 4/28/14 through 6/21/14. The patient did not demonstrate behaviors concerning for him to place himself or other at imminent risk of harm. Psychiatric issues prompting his admission including depression and irritability could have been safely and adequately treated at a less intensive setting. There were no acute impairments, behaviors, or issues with cognition that interfered with the patients ability to perform activities of daily living. Further, psychosocial and environmental problems were not likely to undermine treatment at a less intensive level of care, such as outpatient care. Throughout the admission, he was motivated by earning the reward of a home visit and there was no evidence he required residential care for treatment of his symptoms. All told, the documentation does not indicate the residential treatment services were medically necessary for treatment of this 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 34-year-old female enrollee has requested reimbursement for the gene test provided on 3/17/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees risk for heart disease. The physician reviewer found that the records provided for review document that this patient underwent advanced lipoprotein testing. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including Lp-PLA2, sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis (Lonn; Toole, et al). All told, the gene test provided on 3/17/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The parent of a 13-year-old male enrollee has requested authorization and coverage for Humatrope 24 mg cartridge. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting. This patient had a low annual growth velocity which indicated abnormal growth. His estimated adult height gradually declined to 66 inches, which indicates poor growth. His estimated adult height is below his genetic potential of 71.6 inches. Per the records, he failed growth hormone stimulation testing with a peak less than 10ng/mL, which indicates growth hormone deficiency in the setting of poor growth. Therefore, Humatrope 24 mg cartridge is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 63-year-old male who has been diagnosed with a squamous cell carcinoma of the thymus. In May 2015, he had resection of gross tumor, but was found to have very locally extensive cancer. The surgery was followed by four cycles of chemotherapy along with radiation therapy. This therapy ended in November 2015. He was noted to have progression of disease approximately in October 2016 and was retreated with chemotherapy at that time. As of September 2017, he was relatively stable. A tissue sample was sent for FoundationOne assay. The patient has requested reimbursement for the FoundationOne testing performed on 12/28/16. Per the Health Insurer, the services at issue were investigational for evaluation of this patients medical condition. There is a lack of support for the services at issue in this clinical setting.  FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target, which could inform the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability of the clinician, nor yields a result that is reliably clinically beneficial. There are various non-randomized studies exploring the value of molecular profiling but these studies are not definitive or compelling as to the efficacy of the assay. A randomized study by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular targets. Finding a mutation does not guarantee that a treatment directed at that mutation will produce a clinically meaningful response. All told, the FoundationOne testing performed on 12/28/16 was not likely to have been more efficacious than other methods of evaluating this patients medical condition.   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 sho
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 25-year-old male enrollee has requested reimbursement for corneal crosslinking provided on 8/06/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The records document keratoconus and vision loss. Corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant. Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is a lack of other treatment options available to slow or halt disease progression. Therefore, corneal cross-linking provided on 8/06/18 was likely to have been more beneficial than other available treatment options.