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

Summary  
The patient is a 66-year-old female with a history of spondylolisthesis of the lumbar region, lumbar 
post-laminectomy syndrome, lumbar radiculitis, and lumbar degenerative disc disease. The patient 
has requested arthrodesis of the SI joint, percutaneous, or minimally invasive, for the treatment of 
her back pain. The Health Insurer has denied the requested service as not medically necessary for 
the treatment of the patients medical condition. This denial is the subject of this appeal and 
determination.  The  physician  reviewer  found  that  the  records  provided  for  review  fail  to 
corroborate a diagnosis of SI joint pain for this patient. According to Lorio and colleagues, SI 
joint pain diagnosis is typically accomplished via a clinical diagnostic algorithm involving history, 
physical exam, diagnostic block, and ruling out other pain contributors. Patients with SI joint pain 
typically report pain in the buttock(s), with possible radiation into the groin or upper legs. 
Although the patients CT scan on 9/29/22 did demonstrate mild bilateral SI joint degenerative 
changes, Lorio and colleagues further noted that, No specific imaging modality has demonstrated 
acceptable sensitivity and specificity in the diagnosis of noninflammatory, nontraumatic SI joint 
pain, including plain radiographs, CT, magnetic resonance imaging, and radionucleotide studies. 
In this case, multiple other plausible pain generators, including at the lumbosacral spine, are 
evident. Furthermore, per Shamrock and colleagues, Minimally invasive SI joint fusion is a 
relatively safe procedure but is not without certain risks. Further work must be done to optimize 
the procedure's complication profile. The records provided for review indicate that this patient 
presents with ongoing low back pain and a history of spondylolisthesis of the lumbar region, 
lumbar post-laminectomy syndrome, lumbar radiculitis, and lumbar degenerative disc disease. 
However, there is a lack of documentation reporting a diagnosis of SI joint pain for this patient. 
Overall, there is limited medical literature indicating that arthrodesis of the SI joint, percutaneous 
or minimally invasive is an effective and/or safe treatment for the patients pathology. For these 
reasons, the requested arthrodesis, SI joint, percutaneous, or minimally invasive (CPT 27279 RT) 
is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 53-year-old female enrollee has requested reimbursement for gene testing performed to gauge risk for thyroid cancer on 2/16/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees follicular lesion of undetermined significance.  The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick, et al). For these reasons, the gene testing performed to gauge risk for thyroid cancer on 2/16/17 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 55-year-old male enrollee has requested authorization and coverage for an electrical stimulation device.  The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees medical condition. The physician reviewer found the use of alternating electrical fields via Novocure device is a relatively new type of therapy used in the treatment of brain tumors.  This technique involves the use of a helmet which delivers low-intensity alternating electric fields.  It was approved for use by the U.S. Food and Drug Administration for the treatment of glioblastoma in 2011.  In the study by Stupp and colleagues, 237 patients with recurrent glioblastoma were randomized to either chemotherapy or electrical field therapy.  There was no difference seen in overall survival between the chemotherapy group and the electrical field group.  However, there was noted to be significantly less toxicity in the electrical field group.  All told, the requested device is likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested device is 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: Upheld

Summary Reviewer 

A 53-year-old female enrollee has requested authorization and coverage for PET scan (78816). The Health Insurer has denied this request and reported that the requested services are not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The avidity of fluorodeoxyglucose (FDG) uptake can be helpful in differentiating between benign and malignant solid nodules. Given the resolution limitations of PET, tracer avidity cannot be reliably assessed for nodules with solid components measuring less than 8 mm. The nodules on this patient are 6 mm and below. Thus, the requested PET scan is unlikely to be of utility. Therefore, that PET/CT scan of the whole body with CT scan attenuation (78816) is not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 30-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 6/16/14. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees Crohns disease. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 6/16/14 was not likely to be more effective for this patient than other available treatment options. There is a lack of controlled data supporting the testing for antibodies or adalimumab levels in this clinical setting. The patient demonstrated a clinical and radiographic improvement and was tolerating therapy without problems. There were no infusion reactions or other indications of the development of human anti-chimeric antibodies. Given the lack of support in the peer-reviewed literature, the testing at issue was not likely to be more beneficial than other modalities. Based upon the information set forth above, the testing at issue was 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 3


A 52-year-old female enrollee has requested reimbursement for the Decision Dx melanoma assay provided on 11/18/15. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha (Balch, et al). Currently, there is a paucity of scientific data on the Decision Dx test for melanoma. As such, the test is novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. For these reasons, the Decision Dx melanoma assay provided on 11/18/15 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 patient is a 67-year-old male who presented in 2021 with a prostate-specific antigen (PSA) 
level of 5.64. The patient has requested authorization and coverage for proton beam therapy. 
The physician reviewer found that the submitted documentation fails to demonstrate the 
medical necessity of the requested services. There is a lack of strong medical evidence to 
suggest that treatment with proton beam therapy is associated with a clinical benefit compared 
to standard treatment. Currently, there is insufficient clinical data to discern whether treatment 
with proton beam radiation offers a clinical benefit compared to conventional radiation therapy 
techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent 
multi-institutional analysis of 1,850 patients with low or intermediate risk prostate cancer. The 
authors compared groups receiving hypofractionated radiation proton therapy and intensity 
modulated radiation therapy with photons. This analysis found no significant difference in 
gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found 
no difference in disease control between the two modalities. The American Society of Radiation 
Oncology (ASTRO) Model Policy stated, Proton beam therapy for primary treatment of 
prostate cancer should only be performed within the context of a prospective clinical trial or 
registry. At the present time, ASTRO believes the comparative efficacy evidence of proton 
beam therapy with other prostate cancer treatments is still being developed, and thus the role 
of proton beam therapy for localized prostate cancer within the current availability of 
treatment options remains unclear. The National Comprehensive Cancer Network guidelines 
endorse the position statement by ASTRO and state that no clear benefit of proton beam 
therapy has been demonstrated over standard treatment with photons and intensity 
modulated radiation therapy technique. Therefore, proton beam therapy is not medically 
necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

An 18-year-old female enrollee has requested reimbursement for psychiatric residential treatment provided from 2/17/20 through 3/01/20. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of the enrollees behavioral health conditions. The physician reviewer found that with regard to risk of harm, the records support a score of 4. There was a serious risk of harm, due to suicidal ideation with a recent history of overdose, and the patients stated inability to keep herself safe at home. Additionally, there was recent excessive substance use. In terms of functional status, the records support a score of 3. The patient had moderate functional impairment, due to conflict with her mother and declining grades. With regard to comorbidity, the records support a score of 3. The patient has significant comorbidity, due to alcohol abuse, post-traumatic stress disorder, and depression as well as a recent concussion. In terms of level of stress of the recovery environment, the records support a score of 3. The patient had a moderately stressful environment due to sexual assault and a recent change in school. With regard to level of environmental support, the records support a score of 2. Her parents participated in treatment. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, due to continued symptoms despite outpatient treatment, inpatient hospitalization, and partial hospitalization program and intensive outpatient program treatment. With regard to acceptance and engagement, the records support a score of 2. The patient had initial difficulty being open and honest with treatment providers about the extent of her symptoms. Thus, the patient has a composite score of 21. This score supports medically monitored residence-based services, due to serious risk of self-harm and environmental stress. The submitted documentation supports the services at issue in this clinical setting. Therefore, psychiatric residential treatment provided from 2/17/20 through 3/01/20 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 53-year-old female enrollee has requested reimbursement for gene testing performed on 7/5/16. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees bilateral thyroid nodules. The physician reviewer found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate (Alexander, et al). Until recently, the only method to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases are benign (Miller, et al). The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures (Duick, et al). Therefore, gene testing performed on 7/5/16 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a 14-year-old male enrollee has requested reimbursement and prospective authorization and coverage for psychiatric residential treatment center services provided from 9/19/16 forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the residential treatment center services provided from 9/19/16 forward were and are medically necessary for treatment of the patients medical condition. The medical records show that the patient is aggressive, irritable, critical of others, agitated, rude and argues with peers and staff. There are significant gaps in his ability to modulate his behavior. On 9/22/16, the individual therapy note stated that he presented agitated, critical of others and defensive. He blamed others and was dismissive of feedback. The therapist noted that his struggle with negative self-talk exacerbates his impulsive and disrespectful behaviors. On 9/26/16 the group therapy note stated that the patient struggles with accepting feedback about his behaviors and suggestions of he could improve. The patient argues and becomes defensive, particularly with his disrespect for female staff members was addressed. On 10/2/16, the notes indicate the he continued to be agitated and argued with staff and peers. He continues to be agitated and angry, and becomes unable to be directed and aggressive. Based on the documentation submitted for review, the patient requires the structure and 24-hour setting of continued residential treatment center services in order to allow learned gains to become established prior to discharge to a lower level of care. Therefore, the services at issue were and are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 1/20/17. The Health Insurer has denied this request indicating that the diagnostic procedure at issue was not medically necessary for evaluation of the enrollees right breast lump and discharge from the nipple. The physician reviewer found that Tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration (FDA) in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of mammography, the American College of Radiology (ACR) has urged the technique be removed from the investigational category in 2014 due to the advantage it provides radiologists interpreting mammograms especially in women with dense tissue. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortions resulting in a decrease in callbacks and increase in overall diagnostic accuracy. However, the standard of practice for radiology does not yet require tomosynthesis on all mammography cases. Thus, the use of digital breast tomosynthesis performed on 1/20/17 was not medically necessary for evaluation of this patients right breast lump and discharge. Based on the foregoing discussion, the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that there is extensive literature supporting the testing that was done in this case. The Factor V mutation also known as Factor V Leiden has the potential to induce hypercoagulopathy in certain circumstances. Importantly, the Prothrombin G20210A mutation adds to this risk such that compound heterozygous patients can have increased odds of developing deep vein thrombosis (Emmerich, et al). Similarly, patients with hyperhomocysteinemia and Factor V Leiden are at increased risk for deep vein thrombosis (Ridker, et al). The most common genetic cause for hyperhomocysteinemia is the thermolabile variant of the methylenetetrahydrofolate reductase (MTHFR) enzyme. This is due to homozygosity for the TT genotype at codon 677 (Kluijtmans, et al). If this patient was found to be a carrier of multiple mutations predisposing to thrombosis, then a recurrent thrombotic event could be prevented with medical therapy and activity modification. For these reasons, the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16 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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


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 is sufficient support for the services at issue in this clinical setting.  The medical evidence shows that adjuvant chemotherapy confers a survival advantage for patients with stage III colorectal cancer, but not for those with stage II disease.  Meta-analyses have not shown any survival advantage for 5-FU/leucovorin treatment in stage II patients. The reasons for this conclusion are complex.  Stage II patients do well after surgery alone so that the magnitude of the survival benefit conferred by adjuvant chemotherapy is small; and, randomized clinical trials to date have had too few stage II patients to discern a statistically significant advantage.  Therefore, subset analyses to identify those patients with prognostic features that may predict for chemotherapy benefit have been analyzed.  For example, oncologists consider adjuvant treatment for those stage II patients with T4 disease, obstructing lesions, and other biomarkers.  The Oncotype DX colon cancer assay has been validated independently as being an excellent prognostic indicator.  The medical evidence for the test is sufficient to allow its use to estimate the risk of recurrence for stage II patients when incorporated with other tests such as standard pathology and microsatellite instability testing.  Thus, CPT codes 84999 and 88342 performed on 6/17/16 were likely to have been more effective 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: Upheld

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement for the Decision DX Melanoma assay performed on 6/16/15. The Health Insurer has denied this request indicating that the services at issue are considered investigational for evaluation of the enrollees medical condition.   The physician reviewer found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. This patient has a Stage I melanoma. There is a lack of support in the peer reviewed literature demonstrating the use of gene expression profiling would change the management of treatment for patients with Stage I melanoma. National Comprehensive Cancer Network (NCCN) guidelines state While there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate benign from malignant neoplasms, or melanomas at low versus high risk for metastasis, routine (baseline) genetic testing of primary cutaneous melanomas (before or following [sentinel lymph node biopsy] SLNB) is not recommended outside of a clinical study (trial). Based on the lack of support in the peer-reviewed literature, the Decision DX Melanoma assay performed on 6/16/15 was not likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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.