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

Summary Reviewer 3

A 27-year-old male enrollee has requested authorization and coverage for LINX Reflux Management System (code 43284) and associated inpatient bed day. 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 the current medical evidence has not established the superior efficacy of the requested services. Direct comparative studies between surgical interventions are needed to better assess the long-term safety and efficacy of this therapeutic intervention in patients. There is lack of randomized controlled trials comparing LINX with other surgical anti-reflux interventions, such as the Nissen fundoplication. Sheu and colleagues concluded that the long-term safety and efficacy of LINX remains to be determined by evaluating and investigating the safety, efficacy and durability of the intervention over time. Adverse events including erosion through the esophagus have been reported. Although the LINX device has been approved by the U.S. Food and Drug Administration, based on current evidence and medical literature, the technology has not met a consensus opinion or recommendation by medical societies and governing organizations. The requested service has not been rigorously tested in randomized controlled trials against other alternative therapies. Therefore, LINX Reflux Management System (code 43284) and associated inpatient bed day is not likely to be more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 66-year-old male enrollee has requested reimbursement for gene expression profiling of melanomas performed on 3/29/18.  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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may add to these statistics. DecisionDx-Melanoma testing is an analysis of 31 genes in an individuals melanoma cells. It then classifies that melanoma based on the risk of metastasis in five years. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma classification, in patients who have had sentinel node biopsy. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is also not at all clear if one can make clinical decisions on the basis of DecisionDx-Melanoma classification. Therefore, gene expression profiling of melanomas performed on 3/29/18 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 42-year-old male enrollee has requested authorization and coverage for radiofrequency neurolysis. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees low back and left lower extremity pain.   The physician reviewer found that in the documentation available for review, the provider does not document a pain diary for a medial branch block performed prior to the previous radiofrequency ablation. The current peer-reviewed medical literature is clear about how a diagnostic medial branch block is supposed to be done prior to radiofrequency ablation with use of a pain to verify when the local anesthetic wore off (Derby, et al). In the absence of this information, the requested repeat radiofrequency ablation cannot be supported as 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 2 
 
A 51-year-old female enrollee has requested authorization and coverage for Botox. The Health 
Insurer has denied this request and reported that the requested service is investigational for the 
treatment of the enrollee. The physician reviewer found that in this case, the patient has a history 
of temporomandibular joint disorder which has been present for years. The records note that the 
patient has failed treatment with warm compresses and NSAIDs but responded well to Botox 
therapy of the masseters. Standard therapy currently consists of oral muscle relaxants to help 
reduce muscle spasms, which relax all muscles in the body and therefore have significant side 
effects in order to be effective, physical therapy, which may only provide temporary relief of a 
few hours, and oral appliances, which may prevent dental wear without stopping the bruxism 
that is the primary cause of the temporomandibular joint disorder. Current medical literature 
supports the use of Botox for treatment for bruxism-induced temporomandibular joint disorder. 
Botox treats the bruxism locally and works for three months at a time, allowing the patient three 
months of relief following an injection. In this clinical setting, the use of Botox for the treatment 
of temporomandibular joint disorder is more beneficial than standard treatment as patient's 
condition is caused by bruxism and not cause by arthritis of the temporomandibular joint. 
Therefore, Botox is likely to be more beneficial for treatment of the patients condition than any 
available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

The parent of 10-year-old male enrollee has requested reimbursement for biofeedback treatment services provided from 3/05/18 through 5/14/18. 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 biofeedback is a technique that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Neurofeedback is the type of biofeedback most often cited in research regarding attention deficit/hyperactivity disorder. There is an emerging body of evidence supporting its clinical use. Gonzalez-Castro and colleagues analyzed the efficacy of neurofeedback compared with pharmacological support and the combination of both. In this study, the participants executive control and cortical activation were assessed before and after treatment. The results indicated that the combined group obtained more benefits, and the neurofeedback group improved to a greater extent in executive control than the pharmacological support group. While this recent data has been encouraging, the meta-analysis by Cortese and colleagues noted evidence from well-controlled trials with probably blinded outcomes currently fails to support neurofeedback as an effective treatment for attention deficit/hyperactivity disorder. Goode and colleagues noted there are significant gaps in knowledge regarding the effectiveness of attention deficit/hyperactivity disorder nonpharmacologic treatments. In sum, although recent data has been encouraging, evidence for the use of biofeedback/neurofeedback is still lacking. Thus, biofeedback treatment services provided from 3/05/18 through 5/14/18 was not likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1 
 
A 43-year-old male enrollee has requested reimbursement for injection(s), platelet rich plasma, 
any site, including image guidance, harvesting, and preparation when performed, on 3/7/22. 
The Health Insurer has denied this request and reported that the service at issue was 
investigational for the treatment of the enrollees left elbow pain and bicipital tendinitis of the 
left shoulder. The physician reviewer found that there is insufficient medical literature 
supporting the use of platelet rich plasma (PRP) injections in the treatment of lateral 
epicondylitis and biceps tendonitis. In a metanalysis, Karjalainen and colleagues conclude, 
Data in this review do not support the use of autologous blood or PRP injection for treatment 
of lateral elbow pain. These injections probably provide little or no clinically important benefit 
for pain or function (moderate-certainty evidence), and it is uncertain (very low-certainty 
evidence) whether they improve treatment success and pain relief greater than 50%, or 
increase withdrawal due to adverse events. Wong and colleagues report, Overall there is 
limited robust evidence to recommend PRP therapy for tennis elbow. There is even less 
evidence to support the use of PRP in patients with biceps tendonitis. In this case, the patient is 
a 43-year-old male with left common extensor tendinopathy and biceps tendinopathy. Notes 
dated 9/23/21 reported that meloxicam and topical Voltaren were not helpful in reducing his 
pain. Magnetic resonance imaging (MRI) of the elbow with contrast neurography dated 1/31/22 
showed high signal intensity at the lateral aspect of the epicondyle and distal biceps. The 
patient received an ultrasound guided left distal biceps tendon and left lateral epicondyle 
injection with PRP on 3/7/22. Notes dated 6/13/22 reported that the patients history of 
glucose-6-phosphate dehydrogenase (G6PD) deficiency was the reason a PRP injection was 
provided rather than a steroid injection. It is unclear why G6PD deficiency was a concern for not 
utilizing corticosteroid injection when nonsteroidal anti-inflammatory drugs (NSAIDs) were 
prescribed, which appear to have a higher degree of concern for exacerbating the patients 
condition. Regardless of the patients medical history of G6PD deficiency, current medical 
literature does not support the use of PRP over other standard, conservative treatment options 
such as continued physical therapy. Therefore, injection(s), PRP, any site, including image 
guidance, harvesting, and preparation when performed, on 3/7/22, was not likely to have been 
more beneficial for treatment of the patients condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


The parent of a 14-year-old female enrollee has requested reimbursement for mental health residential treatment center services provided from 11/16/16 through 12/6/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the mental health residential treatment center services provided from 11/16/16 through 12/6/16 were not medically necessary for treatment of the patients medical condition. According to Mehler, Anorexia nervosa is a psychiatric disorder characterized by abnormal eating behaviors that results in weight loss and has serious potential medical consequences. Most of these complications are readily treatable if diagnosed and attended to early in the course of the illness. Outpatient treatment with modalities such as cognitive behavioral therapy (CBT) can be effective for significantly reducing relapse risk and increasing the likelihood of good outcomes compared with nutritional counseling in the treatment of anorexia nervosa (Bulik, et al). CBT is commonly used on an outpatient basis. Moreover, in most cases outpatient treatment is recommended with hospital admission indicated for those at risk of medical and/or psychological compromise (Hay, et al). In this case, the patient was medically and psychiatrically stable. As of 11/16/16 the patient had stabilized and was eating appropriately. She was at 86% of her ideal body weight. Her medical status was intact and described as psychiatrically stable. She had some laboratory abnormalities that could have been addressed on an outpatient basis and she did not have unstable coexisting health problems. She was not exhibiting severe mood, anxiety or psychotic symptoms and was not engaging in self-harm type behaviors. Based on the clinical documentation submitted for review, the patient could have been treated safely and effectively at a lower level of care as of 11/16/16. 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 2 
A 36-year-old female enrollee has requested authorization and coverage for Sunosi 75 mg tablet. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  requested  medication  is 
investigational for the treatment of the enrollees idiopathic hypersomnia. The physician reviewer 
found that the current medical literature supports the use of solriamfetol (brand name Sunosi) as 
successfully improving wakefulness in central disorders of hypersomnolence. In a phase 3 study, 
Thorpy and colleagues reported that  solriamfetol improved wakefulness on the Maintenance of 
Wakefulness  Test  (MWT)  and  reduced  Epworth  Sleepiness  Scale  (ESS)  scores  in  a  large 
population of patients with narcolepsy. The authors also noted the safety and tolerability profile of 
solriamfetol.  However,  there  is  a  lack  of  comparative  studies  showing  that  the  requested 
medication is superior to other available standard therapies. Therefore, Sunosi 75 mg tablet is not 
likely to be more beneficial for treatment of the patients condition than any available standard 
therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 69-year-old male who has requested reimbursement for targeted genomic sequence analysis with Foundation One performed in January 2020. He was diagnosed with a stage IIIA melanoma of the right chest wall in 2014.  The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines recommend that patients with metastatic melanoma have broader genomic profiling if feasible, especially if the test results might guide future treatment decisions or eligibility for participation in a clinical trial. If BRAF single-gene testing is the initial test performed, and is negative (as in this patient), clinicians should strongly consider larger next generation sequencing panels to identify other potential genetic targets. Consideration of broader genomic profiling is recommended if the test results might guide future treatment decisions or eligibility for participation in a clinical trial. There is sufficient support for the services at issue in this clinical setting. Therefore, targeted genomic sequence analysis performed on 1/24/20 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 41-year-old female enrollee has requested reimbursement for Anser IFX testing performed on 4/02/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found the use of Anser IFX to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, and excessive doses are also given, there were no standard guidelines defining a therapeutic strategy at the time of testing.  In sum, the superior efficacy of Anser IFX testing performed on 4/02/15 has not been established.  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 55-year-old female enrollee has requested reimbursement for gene test (molecular profiling) performed on 2/18/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of lung cancer. The physician reviewer found the National Comprehensive Cancer Network (NCCN) guidelines recommend that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged. The NCCN guidelines strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially one by one. This is the most tissue efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time efficient process for screening patients and thus to facilitate prompt treatment or protocol inclusion. For the treatment of patients with advanced NSCLC, broad molecular profiling, such as with Guardant360 testing, is considered a standard of care. Therefore, the gene test (molecular profiling) performed on 2/18/16 was likely to have been of more beneficial than any available standard method for the evaluation of this patients medical condition. Based upon the information set forth 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 2

The patient is a 62-year-old male who was diagnosed with a melanoma on his left parietal scalp with a Breslow depth of at least 1mm.  The patients physician sent his tissue for molecular genetic testing to help determine the risk of spread of the tumor. The patient has requested reimbursement for the DecisionDx-Melanoma test (84999) performed on 1/12/17. The Health Insurer denied this request for reimbursement and reported that the services at issue were considered investigational for evaluation of this patient. In this case, the patient has a scalp/head melanoma. These cancers are associated with a lower yield on sentinel lymph node biopsy (SNLB). His tumor is transected at the base so the records do not provide an accurate Breslow depth but we know it is at least 1 mm.  In order to be able to follow this patient most effectively in terms of risk of recurrence, a molecular study that shows the risk of recurrence would be most helpful. This study would help to stratify this patients risk of recurrence of his tumor after a wide resection. This patients risk would then be used to determine potential treatment and follow up.  In this case, since the SNLB is likely to be negative and it would be difficult to obtain an accurate risk of recurrence, the DecisionDx-Melanoma assay was likely to yield a better result. A complete lymph node dissection is also more difficult in head tumors as they can involve extensive parotid or neck surgeries. All told, the results from DecisionDx-Melanoma test (84999) performed on 1/12/17 was likely to have been more efficacious than the standard options of evaluating 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: Overturned

Summary Reviewer 2


A 43-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/2/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer.  The physician reviewer found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis performed on 9/2/16 was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. 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 3

A 51-year-old female has requested reimbursement for genetic testing performed on 4/13/18. 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 the patient is a 51-year-old female with malignant melanoma. She had a pigmented lesion removed from her right pre-tibial region. The final pathology showed this was superficial spreading malignant melanoma of Breslow depth of 0.8 mm, Clark level IV, and without ulceration. A tumor sample was submitted for DecisionDx-Melanoma testing. The patient has requested reimbursement for genetic testing performed on 4/13/18. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient. 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 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, genetic testing performed on 4/13/18 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.