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

Summary Reviewer 3

A 40-year-old female enrollee has requested reimbursement for homocysteine testing and polymerase chain reaction testing for EBV performed on 8/08/18. 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 Homocysteine has not been found to be a risk factor for cardiovascular disease and should not be ordered as a routine for this purpose. Homocysteine levels may be useful in evaluating patients who are symptomatic of B12 deficiency, but have normal or borderline B12 levels. The medical records do not indicate findings consistent with B12 deficiency, such as macrocytic anemia or psychiatric complaints. It appears that B12 therapy was planned to be continued regardless of homocysteine level results. Thus, homocysteine testing and polymerase chain reaction testing for Epstein Barr virus performed on 8/08/18 were not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


The parent of a four-month-old male enrollee has requested reimbursement for the nitric oxide therapy provided from 11/4/16 through 11/7/16. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees respiratory distress syndrome.   The physician reviewer found that the patient was born at 28 weeks gestation on 11/2/16 and had neonatal respiratory distress syndrome causing pulmonary hypertension. The patient was intubated and treated with three doses of surfactant. Despite this treatment, on 11/4/16 the patient was hypoxic with oxygen saturation decreasing into the 60% range. An echocardiogram revealed pulmonary hypertension. As noted by the U.S. Food and Drug Administration (FDA), inhaled nitric oxide is a pulmonary vasculature dilator approved treatment for neonatal pulmonary distress syndrome with pulmonary hypertension. The pulmonary hypertension must be treated immediately to prevent large shunting of deoxygenated blood. Given this indication, the inhaled nitric oxide provided to this patient from 11/4/16 through 11/7/16 was consistent with standard of care and therefore was medically necessary.  Based on the foregoing discussion, the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 19-year-old male who has a long history of back and shoulder pain. He has been seen by a chiropractor on multiple occasions and has been treated conservatively. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Pain is a common complaint, and not everyone who has pain needs a CT or MRI scan. As a fundamental principle, an imaging study is only worthwhile if it will affect the management of the patient. In this patient, especially considering the negative thoracic spine CT scan, the likelihood of detecting a significant abnormality that would have changed the management was minimal. The fact that the patient had a negative CT scan of the thoracic spine would exclude likely culprits (in a patient of this age) such as a scoliosis, mild degenerative change, or anatomic variations such as a hemivertebral body. In the absence of any of these findings, especially in a young active patient who has a recent history of hurting his back after playing sports, the likelihood of MRI providing any significant information is minimal.
As has been shown in multiple studies, incidental finding of degenerative disease or disc abnormality is exceedingly common in asymptomatic individuals. It is well known that some patients with substantial MRI findings will not have symptoms, and conversely, some patients with minimal signs on MRI will have pronounced symptoms. The American College of Radiology has established aAppropriateness Criteriaa to help referring physicians obtain efficient use of imaging modalities to evaluate various clinical presentations. While they have not established specific criteria for thoracic spine pain, they have established these criteria for chronic neck and low back pain. MRI is felt to be anot usually appropriatea in the management of chronic pain without other red flags. This patient had no symptoms other than pain, which he reports having had for at least the last year. There is no evidence of radiculopathy, prior tumor, or infection. The medical evidence does not support the services at issue in this patientas case. Therefore, the MRI performed on 7/01/20 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 61-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/31/18. 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 also been thought to add a bit to these statistics. DecisionDx-Melanoma testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma based on the five-year risk of metastasis. Gerami and colleagues reported on 217 cases, with a good correlation between the DecisionDx-Melanoma testing and prognosis in patients who have had sentinel node biopsy. Berger and colleagues reported on 156 cases, but there was not sufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma testing data compares to the ten-year Balch data. Most importantly, it is not known if the DecisionDx-Melanoma testing result can be used to make clinical decisions. Therefore, DecisionDx-Melanoma testing performed on 10/31/18 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of an eight-year-old male enrollee has requested reimbursement for FirstStep Dx Plus testing performed on 5/28/14.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the treatment of the enrollees autism spectrum disorder (ASD). The physician reviewer found the FirstStep Dx Plus testing performed on 5/28/14 was likely to be more effective for this patient with autism than other available treatment options. CMA testing is the first-line genetic testing when there are findings suggesting an underlying genetic etiology. The medical literature demonstrates that this test has become an important and mainstream tool in the practice of clinical genetics. The study by Henderson and colleagues retrospectively reviewed the medical records of patients who had abnormal chromosomal microarray findings reported per laboratory over a three-year period and quantified the management recommendations made in response to these results. The authors concluded that These results empirically demonstrate the clinical utility of chromosomal microarray by providing evidence that management was directly affected for the majority of patients in our cohort with abnormal chromosomal microarray findings. Based on the support in the medical literature, the testing at issue 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 


A 54-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this clinical setting.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions.  It is advantageous to treat patients before they progress to F3 or F4 fibrosis.  Based on published evidence of safety and efficacy in the medical literature, Harvoni is medically indicated for the treatment of this patient.  Therefore, 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 1 
 
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 recently diagnosed with advanced non-small 
cell  lung  cancer.  The  mutational  landscape  of  non-small  cell  lung  cancer  has  significantly 
expanded in the past few years to encompass gain of function in multiple oncogenes with major 
prognostic and therapeutic implications (Rolfo, et al.). This patients genetic testing was for 
mutually exclusive somatic driver mutations, which is consistent with the standard of care. 
Typically, KRAS, TP53, and BRAF are included in these panels and have been shown to be 
informative in treatment planning. Primary tumor tissue by next-generation sequencing is the 
preferred method for identifying actionable driver mutations. The patients requisition form stated 
that primary tumor sampling was not feasible. For these reasons, 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 2

A 52-year-old female enrollee has requested reimbursement for colorectal cancer screening; stool-based DNA and fecal occult hemoglobin performed on 9/16/15. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Conventional assessment of colorectal cancer (CRC) risk largely involves detection of non-dysplastic adenomatous polyps. The efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against the gold standard optical colonoscopy. Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers (KRAS mutations, NDRG4, and BMP3 methylation) and a non-DNA immunochemical assay for human hemoglobin. However, Cologuard and ColonSentry demonstrate inadequate sensitivity to detect precancerous lesions which is the point of colon cancer screening. Despite that the patients migraines with conventional testing, the stool-based DNA and fecal occult hemoglobin performed 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 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 58-year-old male enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees severe and persistent asthma. The physician reviewer found the current medical evidence supports the requested services in this clinical setting.  Initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed.  Cox and colleagues examined 112 subjects with moderate to severe asthma, and the authors noted that bronchial thermoplasty resulted in improved asthma control.  Pavord and colleagues examined the safety of thermoplasty and found short-term worsening in symptoms, but evidence of improved long-term control of asthma.  Castro and colleagues compared thermoplasty with a sham procedure and followed the patients for 12 months as well.  The authors found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group.  In this patients case, he is on a very aggressive regimen of bronchodilators along with antihistamines and Xolair.  There is little left in the standard armamentarium to control his refractory symptoms.  All told, the requested bronchial thermoplasty is medically indicated for the treatment of this patient.  Therefore, the requested services are medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 49-year-old female enrollee has requested authorization and coverage for insulin infusion pump. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees diabetes, type I. The physician reviewer found that there is sufficient support in the medical literature for the requested device in this clinical setting. The patient has diabetes, type I and has managed her diabetes well in the past with insulin pump therapy. However, the tubeless OmniPod pump has malfunctioned and she has developed allergic reactions to its adhesive, preventing the pump from staying in place. Therefore, the patient is being administered suboptimal doses of insulin. Her hemoglobin A1c has gone up from 7 to 8.1 percent, which goes against the goals of diabetes management (2017- Standards of Medical Care in Diabetes). The patients provider has requested a replacement, because the OmniPod is no longer working for this patient. The need to work with the patient is written in the guidelines by the American Diabetes Association and the American Association of Clinical Endocrinologists. The records document that this patient has not responded well to her current OmniPod system and she has had adverse effects. While skin hypersensitivity to adhesives or cannulas at the insertion site is not common, it is an issue that occurs in some patients and addressed in the literature. In this patients case, staying on the OmniPod system is no longer effective and safe. The patient has attempted to work with this pump, unsuccessfully. All told, the requested insulin infusion pump is medically necessary for the management of this patients diabetes.Therefore, for all the reasons stated above, the requested device is 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 49-year-old male enrollee has requested reimbursement for residential substance use disorders treatment provided from 3/27/17 through 4/22/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment. The records do not demonstrate that comprehensive, evidence-based services provided a less restrictive treatment setting would have been insufficient or inadequate. The patient had been engaged in hospital based care or supervised detoxification services since 3/05/17.  He was frightened by his most recent alcohol withdrawal syndrome and motivated for recovery. He had no alcohol cravings. He had a supportive girlfriend who insisted on sobriety which contributed to an environment conducive to recovery. He had not been active in chemical dependency treatment during the episode of illness.  His mental status examination had no concerning entries. He had a chronic limp but no medical or psychiatric conditions that would warrant a residential placement. All told, residential substance use disorders treatment provided from 3/27/17 through 4/22/17 were not medically necessary for the treatment of this patient. 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: Overturned

Summary Reviewer 3 
A 46-year-old female insured has requested authorization and coverage for lymphedema surgery 
and two inpatient bed days. The Health Insurer has denied this request indicating that the requested 
services  are  considered  investigational  for  treatment  of  the  insureds  lymphedema.  
The physician reviewer found that an exhaustive review of the current medical literature pertaining 
for microsurgical treatment of lymphedema reveals that this procedure has been performed for 
many years with a high degree of success. Basta and colleagues published a meta-analysis of 27 
studies with 91% of patients showing improvement of their symptoms in their lymphovenous 
microsurgery and tissue transplantation. The patient has tried multiple nonsurgical interventions 
without substantial improvement. Given the rigorous scientific review lymphedema surgeries with 
demonstrated success, the requested lymphedema surgery is likely to provide the patient with an 
improved health outcome when compared to standard therapies. For these reasons, the requested 
lymphedema surgery and two inpatient bed days is likely to be more beneficial for treatment of 
the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 29-year-old female enrollee has requested reimbursement for allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. Food-specific immunoglobulin G (IgG) level does not predict true food hypersensitivity and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. Thus, food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) level for foods and skin testing. IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy in children for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95 percent. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. A negative skin test result indicates the absence of an IgE-mediated allergy upon subsequent challenge with a 90 to 95 percent predictive accuracy. Therefore, allergen specific immunoglobulin G (IgG) (RAST/ELISA) for routine allergy testing performed on 3/22/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 48-year-old male enrollee has requested authorization and coverage for intravenous immune globulin (IVIG). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees specific antibody dysfunction. The physician reviewer found the treatment of specific antibody deficiency with replacement immunoglobulin remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine (Prevnar 7 or 13), aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, increased vigilance and appropriate antibiotic therapy for infections, prophylactic antibiotics and IVIG. Replacement IGIV is an option for patients with proven recurrent infections that persist after immunizing with conjugate vaccines and appropriate antibiotic treatment (Cohn, et al.). However, studies have demonstrated that prophylactic antibiotic therapy may be as effective as replacement immunoglobulin (Gelfand, et al). In this case, the patient is not on an antihistamine for his elevated IgE and there is no evaluation of his most likely allergic component to his symptoms. The patient has not been vaccinated with the conjugate pneumococcal vaccines. There is also no documentation of a trial of prophylactic antibiotics. Moreover, IVIG is a pooled blood product and there are significant risks involved in the administration of IVIG including thrombosis, renal dysfunction, acute failure and infection. The documentation does not support that IVIG is safe and effective for the patient. In addition, there is no documentation other therapies used and failed such as aggressive allergic rhinitis treatment, vaccinated with conjugate pneumococcal vaccine or trial of prophylactic antibiotics in the patient. Therefore, the request for IVIG is not medically necessary in this clinical setting. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.