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

Summary Reviewer 1


A 55-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/02/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic. The physician reviewer found that there is sufficient support for the service at issue in this clinical setting. Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with very dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional mammographic protocol was likely of greater benefit to the patient than had her mammogram been done with two-dimensional imaging alone.  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: Overturned

Summary Reviewer 1


A 40-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 9/9/16. 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 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 9/9/16 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 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 2

A 48-year-old male enrollee has requested authorization and coverage for cervical artificial discectomy and second level cervical discectomy.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.  The physician reviewer found thatthe requested cervical artificial discectomy and second level cervical discectomy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Two level total disc arthroplasty has become accepted by the neurological community to be superior to a two level anterior cervical discectomy and fusion (ACDF) especially in younger patients, such as in this case. There is a growing body of evidence in the peer-reviewed literature that demonstrates two level total disc replacement is associated with a lesser incidence of adjacent level disease than a two level anterior cervical fusion.  Given, the above, the requested services are 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 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: Overturned

Summary Reviewer 3

A 60-year-old male enrollee has requested reimbursement for Oncotype DX prostate cancer assay (CPT code 84999) testing provided on 4/11/16. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees elevated prostate-specific antigen (PSA). The physician reviewer found that the Oncotype DX prostate cancer assay (CPT 84999) testing performed on 4/11/16 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. This patient underwent genomic testing to help in clinical decision making. In this case, given the patients Gleason score of 6, PSA, and volume of cancer detected, current guidelines without genomic testing place this patient at low risk. In conclusion genomic testing 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 61-year-old female enrollee has requested authorization and coverage for breath hydrogen/methane test (91065). The Health Insurer has denied this request and reported that the requested services are investigational for the evaluation of the enrollees medical condition. The physician reviewer found that this patient presented with abdominal pain and gas after antibiotic use, potentially consistent with small intestinal bacterial overgrowth, although accurate and definitive diagnosis can be challenging. Hydrogen breath testing is the most widely available and widely used diagnostic test for small intestinal bacterial overgrowth. Testing for both hydrogen and methane increases the sensitivity of the breath test, and is a considerable improvement over hydrogen testing alone. Antibiotics are necessary for treatment if the results are positive, so confirmation of small intestinal bacterial overgrowth with breath testing can allow avoidance of unnecessary antibiotic use. Thus, breath hydrogen/methane test (91065) is likely to be more efficacious than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 34-year-old male enrollee has requested authorization and coverage for Bicillin L-A. The Health Insurer has denied this request indicating that the requested medication is investigational for the treatment of the enrollees medical condition.  The physician reviewer found Bicillin is a long acting form of penicillin G which generates protracted low levels of penicillin in the blood and has been used primarily for the treatment and prevention of streptococcal infections. It has also been used in the therapy of syphilis and related spirochetal infections. However, there is a lack of published medical literature that supports the use of this drug in the treatment of Lyme disease. Moreover, it is not a recommended therapy per the Infectious Diseases Society of America guidelines (Wormser, et al). Therefore, the use of Bicillin L-A 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 55-year-old male enrollee has requested reimbursement for Oncotype DX Prostate testing performed on 1/24/19. 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 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 prostate-specific antigen (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 (i.e., surgery or radiation) and may be followed closely instead. Oncotype DX Prostate testing is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. The current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients. Oncotype DX Prostate testing is an appropriate test in this context. The National Comprehensive Cancer Network guidelines also suggest the use of this test to better stratify such patients with localized disease. Thus, Oncotype DX Prostate testing performed on 1/24/19 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 25-year-old male enrollee has requested authorization and coverage for Stelara injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hidradenitis suppurativa. The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. HS is a painful and debilitating disease that affects physical and emotional health of patients. The apocrine glands become diseased. There are only a few U.S. Food and Drug Administration approved medications for the treatment of HS.  The evidences show that most patients have recalcitrant disease even with surgery and medical treatment. Recently, the pathophysiology of HS is thought to be immunologically influenced and the IL12/23 pathway is implicated in HS based on small studies demonstrating expression of IL12/23 in macrophages infiltrating HS lesioned skin and infiltration of the HS dermis by IL17 producing T-helper cells. Several small case reports of patients experiencing improvement in disease have been published with Stelara (ustekinumab), which blocks IL12/23. The submitted documentation indicates that this patient has failed numerous standard therapies. Smoking and obesity are known to increase disease activity, so smoking cessation would be important for this patient. However, the provider noted that the patient is doing well on the Stelara injections. This patient meets the criteria for the administration of this medication. Accordingly, Stelara injections have been demonstrated as medically necessary for treatment of this patients medical condition. Therefore, based on the information noted above, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 43-year-old male enrollee has requested reimbursement for the left eye corneal collagen cross-linking provided on 7/21/16. The Health Insurer has denied this request indicating that the services at issue are considered investigational for treatment of the enrollees progressive keratoconus. The physician reviewer found that Collagen cross-linking was recently approved in the U.S. as a treatment for progressive keratoconus (Jeng, et al; Sykakis, et al). In this case, while the records state that there was progression in the left eye, there is a lack of evidence consisting of topography, manifest refraction, and pachymetry provided for the review. Therefore, since none of the historic results of the objective tests that demonstrate the progression have been provided, the left eye corneal collagen cross-linking provided on 7/21/16 was 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 41-year-old male enrollee has requested authorization and coverage for a spine procedure. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the medical literature supported the Intracept procedure in this setting. The current modalities for these patients is either fusion or artificial disc replacement. Intracept procedure offers a far less invasive outpatient procedure, avoiding either fusion and or artificial disc replacement, while maintaining the structural integrity of the spine. Based on evidence-based literature, patients have been shown to have significant improvements in pain following the Intracept procedure. Therefore, the requested spine procedure is likely to be more beneficial for the treatment of the patientas medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 60-year-old female enrollee has requested reimbursement for genomic analysis performed on 6/15/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ovarian cancer. The physician reviewer found that the current medical evidence supports a portion of the services at issue. FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. It has not been determined if molecular markers are useful in treatment determination (predictive markers). There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Patients who are microsatellite instable (MSI) can be treated with Keytruda. In this patients case, there is support for MLH1, MSH2, MSH6 and PMS2 testing. However, the superior efficacy of the remaining of the services at issue has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 42-year-old female enrollee has requested reimbursement for emergency room and related services provided on 4/10/15. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found that the  issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing an emergency medical condition on the date in dispute. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a sudden onset low back and flank pain, nausea, and dizziness. There are many serious medical conditions which may cause similar intense symptoms. These range from acute ureterolithiasis, aortic dissection, appendicitis, perforated viscous, pyelonephritis, herniated disc, and ovarian torsion.  The patient attempted to treat her condition with ibuprofen at home. When that failed, she sought emergency medical evaluation. The etiology of the patients pain was unclear to the emergency physician and a thorough evaluation was performed to determine the cause of the symptoms. In sum, a prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the services provided on 4/10/15 met prudent layperson criteria for emergency care.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 68-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 12/06/17. 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 this patient had an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical trial. 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, and 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 12/06/17 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 45-year-old female enrollee has requested reimbursement for Privigen (intravenous immune globulin or IVIG) from 10/10/16 through 4/10/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees relapsing remitting multiple sclerosis. The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue in this clinical setting. The patient has been diagnosed with relapsing remitting multiple sclerosis. While she has tried two interferons, Copaxone and Tecfidera, for primary disease modification, there are currently numerous other medications that are available for the treatment of relapsing remitting multiple sclerosis which this patient has not tried. The patient has the option of considering other medications such as Tecfidera, Tysabri, and Zinbryta prior to considering the use of Privigen. Moreover, Privigen is not U.S. Food and Drug Administration approved disease modifying agent for the treatment for RRMS. Therefore, for the reasons stated above, Privigen (intravenous immune globulin or IVIG) is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 68-year-old female enrollee has requested DecisionDX melanoma assay test performed on 6/19/15.  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 current medical evidence supports the services at issue in this clinical setting.  The DecisionDx melanoma assay test is considered a standard of care for determining if adjuvant therapy is needed to treat patients with uveal melanoma. Using samples of primary uveal melanomas obtained by fine needle biopsy, tumors are classified as having low (class 1) or high (class 2) metastatic potential, depending on the expression of 15 genes.  In sum, the DecisionDX melanoma assay test was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 39-year-old female whose history is significant for having a child with Coffin-Siris syndrome with a mutation noted in SMARCA4. She has requested reimbursement for SMARCA4 gene mutation and chromosome testing performed on 8/14/17. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of this patient.  Given the patients age and prior affected child, testing for both fetal aneuploidy and the known gene mutation were medically appropriate. While the initial plan was to perform testing with chorionic villus sampling, the procedure did not yield adequate villi for testing. The patient then underwent cell-free fetal DNA testing for fetal aneuploidy.  This was medically indicated since the American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine recommend cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. Due to the patients age, the aneuploidy risk for this patient warranted cell-free DNA testing for aneuploidy.  Since this test would not address the recurrence risk of the SMARCA4 mutation in the current pregnancy, the patient then underwent amniocentesis. While the testing for the SMARCA4 gene mutation in the amniotic fluid was medically indicated, there was no medical indication to perform a karyotype on the amniotic fluid, as the cell-free fetal DNA was normal. In sum, the testing for SMARCA4 gene mutation was likely to have been more effective than other methods of evaluating this patient, but the superior efficacy of the chromosome testing on 8/14/17 has not been established. Based upon the information set forth above, a portion of the services 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 partially overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1 
 
The parent of a 13-year-old female enrollee has requested reimbursement for needle 
electromyography (EMG) of anal or urethral sphincter, any technique; needle 
electromyography, each extremity; and electroencephalogram performed on 6/10/20. 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 medical evidence supports the services at issue in this clinical setting. This 
patient was being treated for adolescent idiopathic scoliosis. She underwent a thoracoscopic 
anterior spinal tethering. This procedure involved a high risk of significant complications. The 
use of electromyographical monitoring has been found beneficial to help prevent further injury 
during this procedure. Therefore, needle electromyography (EMG) of anal or urethral sphincter, 
any technique; needle electromyography, each extremity; and electroencephalogram 
performed on 6/10/20 was likely to have been more beneficial than any available standard 
therapy.