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

Summary Reviewer 1

A 21-year-old female enrollee has requested reimbursement for greater occipital nerve injection provided on 11/21/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees occipital neuralgia. The physician reviewer found that the records document a diagnosis of bilateral greater occipital neuralgia. Based on a review of the medical record, the patients conditions may be exacerbated as a result of the occipital neuralgia. The use of nerve blocks for the treatment of occipital neuralgia is well-established and is known to be an effective method of treatment for this condition. Furthermore, the treatment of this condition may result in improvement of the patients chronic migraines, as occipital neuralgia is known to be secondary cause for exacerbation of migraines. Therefore, greater occipital nerve injection on 11/21/17 was likely to have been more effective than other treatment options. Based upon the information set forth above, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 54-year-old male enrollee has requested reimbursement for DecisionDx melanoma test performed on 11/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented with a mole on his left upper back.   The physician reviewer found that the records indicated that this patient does not have melanoma, hence ordering the melanoma decision DecisionDx melanoma test was not indicated. The diagnostic test DecisionDx melanoma test is considered experimental. The test claims to determine risk of recurrence for early melanoma in patients with stage I or II. There is a lack of data to support using immunotherapy in the early stages of melanoma regardless of the recurrence risk. Furthermore, prospective randomized data for determination of recurrence risk is lacking for this test. For these reasons, DecisionDx melanoma test performed on 11/9/16 was not likely to be more effective than the other methods for the evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for Harvoni. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus. The physician reviewer found the requested medication is not medically necessary for treatment of the patients HCV. The documentation submitted for review fails to demonstrate evidence of the patients use of alcohol or drugs, duration of infection, presence or absence of extrahepatic manifestations. In addition, there is a lack of documentation provided about the general health of this patient to anticipate longevity. There are no hepatic imaging included as well. Given the lack of support provided within the clinical documentation submitted for review, Harvoni is not medically necessary for treatment of this patients medical condition. asons provided, the requested medication is 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 52-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma gene expression testing performed on 11/01/18. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has been thought to add a bit to the statistics. DecisionDx-Melanoma gene expression testing is a study of 31 genes in the cells of an individuals melanoma. It then classifies the melanoma based on the five-year risk of metastases. Gerami and colleagues reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients having sentinel node biopsy. Berger reported on 156 cases, but there was not sufficient follow-up to determine the clinical value of the assay. It is not known how the five-year DecisionDx-Melanoma data compares and relates to the 10-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma class can be used to make clinical decisions. Therefore, DecisionDx-Melanoma gene expression testing performed on 11/01/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 64-year-old female enrollee has requested authorization and coverage for implantation of a nerve stimulator. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees moderate obstructive sleep apnea (OSA). The physician reviewer found that Hypoglossal nerve stimulation is a new and emerging treatment for OSA. However, the current literature does not provide sufficient evidence of efficacy. While sleep endoscopy is frequently utilized for evaluation, there are no standard parameters to determine optimal candidates for hypoglossal nerve stimulation, nor have the findings of the original studies been replicated, which is a standard within medical research. Given the inability to support conclusions on efficacy and patient outcomes, the requested implantation of a nerve stimulator 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 service 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: Experimental
Decision: Overturned

Summary Reviewer 3 
A 68-year-old female insured has requested reimbursement for a Guardant360 CDx test provided 
on 1/19/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insured's metastatic non-small cell lung cancer. 
The physician reviewer found that this patient was diagnosed with metastatic non-small cell lung 
cancer. The U.S. Food and Drug Administration (FDA) has approved several targeted therapeutic 
agents and inhibitors to support the role for genetic testing in the evaluation of patients with 
metastatic cancer. Per the NCCN, It is recommended at this time that when feasible, testing be  performed  via  a  broad,  panel-based  approach,  most  typically  performed  by  next-generation 
sequencing. Specifically, select tropomyosin receptor kinase (TRK) inhibitors have been FDA-
approved for patients with neurotrophic tyrosine receptor kinase (NTRK) gene fusion-positive 
solid tumors. Moreover, several agents have been FDA-approved for EGFR, ALK, ROS1, BRAF, 
and MET gene mutations or alterations. Next-generation sequencing-based testing including 
Guardant360 CDx has been reported to potentially identify targetable gene mutations or alterations 
with actionable treatment options. Furthermore, the NCCN endorses next-generation sequencing-
based testing such as Guardant360 CDx in the setting of patients with metastatic non-small cell 
lung cancer. As such, the Guardant360 CDx test provided on 1/19/22 was likely to be more 
beneficial for the evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 54-year-old female enrollee has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT). The Health Insurer has denied this request indicating that the requested diagnostic procedure is considered investigational for evaluation of the enrollees left breast carcinoma. The physician reviewer found that the role of PET/CT in the staging and surveillance of solid tumors of all types including breast is well known and accepted in the medical community. In this particular patient where there is imaging suspicion of tumor recurrence in the left internal mammary chain in a location where biopsy cannot be safely performed the role of PET/CT is ideal. If the conspicuous nodes are of high SUV they can be presumed metastatic in nature and appropriate treatment initiated. If they are of low SUV watchful waiting would be necessary. There is no other test which would be of such benefit in this particular patient. Thus, the requested PET/CT is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, I have determined the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 50-year-old female enrollee has requested reimbursement for CPT codes 84999 (unlisted chemistry procedure, Oncotype DX colon cancer assay) and 88342 (immunohistochemistry of immunohistochemistry, per specimen, initial single antibody stain procedure) performed on 6/17/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found that it is clear that adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer.  However, it is much more controversial as to the usefulness of adjuvant chemotherapy in stage II colon cancer, as in this patients case.  Most oncologists make this decision based on specific pathologic and clinical features in an individual.  Among those features that predict for a higher risk of recurrence are poorly differentiated histology, lymphovascular invasion, presentation with obstruction or perforation, or a T4 tumor.  Of these features, only the fact that it was a T4 tumor is applicable here, suggesting the possible need for adjuvant chemotherapy.  Oncotype DX colon cancer assay is a 12-gene panel that appears to predict the risk of recurrence in both stage III and stage II colon cancer, which goes beyond the pathologic features noted above.  There is sufficient support for the services at issue in this clinical setting, with only one bad feature (that is a T4 tumor), wherein the decision about adjuvant chemotherapy is difficult.  Therefore, CPT codes 84999 and 88342 performed on 6/17/16 were likely to have been superior over other 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 3
A 67-year-old female enrollee has requested reimbursement for the intraoperative radiation therapy performed on 7/19/16. The Health Plan has denied this request indicating that the service at issue is considered investigational for treatment of the enrollee breast cancer. The physician reviewer found that the IORT performed on 7/19/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The American Society for Radiation Oncology (ASTRO) consensus guidelines for accelerated partial breast irradiation recommend low-energy x-ray IORT be used within the context of a prospective registry or clinical trial. ASTRO guidelines further state that when IORT is used it should be restricted to women with invasive cancer considered suitable for partial breast irradiation. In this case, based on the clinical documentation provided for review the patient is not considered suitable candidate given she has pure DCIS. Thus, IORT is not clinically indicated for this patient. For the reasons provided, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 43-year-old female enrollee has requested reimbursement for the screening digital breast tomosynthesis performed on 6/17/16. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed on 6/17/16 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 diagnostic procedure 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 2

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. 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 Chromosomal microarray (CMA) is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorders. CMA has become the standard of care for diagnosis in patients with autism spectrum disorders. Increasing numbers of patients with autism spectrum disorders have been found to have underlying copy number variations. As such, it is possible that some copy number variations have also been associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with autism spectrum disorders due to that underlying cause. Additionally, copy number variations on CMA may inform about possible other complications and medical risks, some of which can be screened for and treated. Therefore, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 21-year-old male enrollee has requested reimbursement for a PET scan performed on 7/23/19. 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 this patient has a history of synovial sarcoma. According to the National Comprehensive Cancer Network (NCCN) guidelines for soft tissue sarcoma, Positron emission tomography (PET) may be useful to clarify if computed tomography (CT) or magnetic resonance imaging (MRI) are ambiguous. In light of the areas of involvement for this patient, such as the left ventricle, a PET scan was indeed useful. Three months had elapsed since the previous scan. The timing was also appropriate according to the NCCN guidelines. The medical evidence supports the services at issue in this clinical setting. Thus, PET scan performed on 7/23/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 41-year-old male enrollee has requested authorization and coverage for CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure). 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 U.S. Food and Drug Administration has approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria. Based upon a prospective study by Lipham and colleagues that included 44 patients, the mean total percent time pH was less than 4 was reduced from 11.9 percent at baseline to 3.8 percent at three years. Reynolds and colleagues performed a study comparing the LINX procedure with laparoscopic fundoplication. The authors found that patients with gastroesophageal reflux disease had similar control of reflux symptoms after both LINX and fundoplication. The inabilities to belch and vomit were significantly fewer with LINX, along with a significantly lower incidence of severe gas-bloat symptoms. Finally, a five-year cohort data by Ganz and colleagues established the durability of the device. In a group of 85 patients, augmentation of the lower esophageal sphincter with a magnetic device provided significant and sustained control of reflux, with minimal side effects or complications. The authors noted that no new safety risks emerged over a five-year follow-up period. All told, CPT 43284 (laparoscopy, surgical, esophageal sphincter augmentation procedure) is likely to be more beneficial than other available treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
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 IH is a diagnosis of exclusion. Its true incidence is unknown and there is a lack of 
specific trials for treatment of excessive daytime sleepiness due to IH. There is currently only one 
medication, Xywav, a mixed-salt oxybate, specifically indicated by the FDA for the treatment of 
IH. All the commonly prescribed agents for IH are used on an off-label basis. These agents are 
specifically labeled for the treatment of other hypersomnolence states, such as residual sleepiness 
after adequate treatment of obstructive sleep apnea with continuous positive airway pressure 
(CPAP) therapy or in narcolepsy. As Sunosi has only been on the market since 2019, there is a 
lack of data or studies in current medical literature regarding its use in IH. 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 69-year-old female enrollee has requested reimbursement for lipoprotein (a) testing performed on 2/09/21. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. At issue is whether the services at issue were likely to have been more beneficial for evaluation of the enrolleeas condition than any available standard therapy. The physician reviewer found that there is a lack of support for the services at issue in this patientas case. The National Lipid Association stated that lipoprotein (a) testing is reasonable to refine atherosclerotic cardiovascular disease risk in adults with the following: first-degree relatives with premature atherosclerotic cardiovascular disease (less than 55 years of age in men; less than 65 years of age in women); a personal history of premature atherosclerotic cardiovascular disease; primary severe hypercholesterolemia (LDL of 190 mg/dL) or suspected familial hypercholesterolemia. This patient does not meet any of these criteria for lipoprotein (a) measurement. Therefore, lipoprotein (a) testing performed on 2/09/21 was not likely to have been more beneficial than other available methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 53-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma test performed on 11/06/19. 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 the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit to these statistics. DecisionDx-Melanoma test is a study of 31 genes in an individualas melanoma cells. It then classifies that melanoma into either Class 1 or 2, with a difference in the risk of recurrence at five years between these two classes. Gerami and colleagues reported on 217 cases, with good correlation between such molecular assay and prognosis in patients who had undergone sentinel node biopsy. At this time, it is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. In this case, the Balch data provides sufficient information to make clinical decisions, and DecisionDx-Melanoma was not likely to have added to this information. Therefore, DecisionDx-Melanoma test performed on 11/06/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

The parent of a four-year-old male enrollee has requested reimbursement for chromosomal microarray testing provided on 11/12/18. 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 sufficient support for the services at issue in this clinical setting. According to the American College of Medical Genetics and Genomics, chromosome microarray testing is first-line testing in autism disorders. Battaglia and colleagues noted that chromosome microarray testing is a first tier test for individuals with autism or intellectual disability. There is sufficient literature at this time to consider chromosome microarray testing a first-line diagnostic assay in this case. Thus, chromosomal microarray testing provided on 11/12/18 was likely to have been more beneficial than other methods of evaluating this patient.