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

Summary Reviewer 1

A 35-year-old male enrollee has requested authorization and coverage for 64568 and 0466T. 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 Inspire hypoglossal nerve stimulation (HNS) device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure (CPAP). However, a meta-analysis by Kompelli and colleagues found that contemporary HNS research consisted of single-arm clinical trials and case series, with a high likelihood of publication bias and a lack of comparative trials of HNS versus existing alternatives such as upper airway surgery. They concluded that HNS may not be the definitive choice for second line therapy for obstructive sleep apnea. In this case, clinical encounter notes did not mention uvulopalatopharyngoplasty (UPPP) or oral/dental appliances as options, despite physical examination findings that appeared to involve primarily the soft palate. Overall, there is insufficient high-quality, peer-reviewed evidence to support the use of HNS over other available therapies. Therefore, 64568 and 0466T are not likely to be more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


The parent of a two-year-old male enrollee has requested reimbursement for FirstStepDX Plus chromosomal microarray analysis.  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 that CMA is increasingly utilized for genetic testing of individuals with unexplained developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  CMA offers a much higher diagnostic yield for genetic testing of patients with unexplained developmental delay/intellectual disability, autism spectrum disorder, or multiple congenital anomalies than the previous standard testing with G-banded karyotype, primarily because of its higher sensitivity for submicroscopic deletions and duplications.  Available evidence strongly supports the use of CMA in place of G-banded karyotyping as the first-tier cytogenetic diagnostic test for patients with developmental delay/intellectual disability, autism spectrum disorders, or multiple congenital anomalies.  Given that the standard of care is now CMA, the FirstStepDx Plus chromosomal microarray was likely to have been of greater benefit than other methods of evaluation.  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 2

The parent of seven-year-old female enrollee has requested reimbursement for individual psychophysiological therapy incorporating feedback training by any modality with psychotherapy services provided from 10/31/14 through 12/9/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees attention-deficit/hyperactivity disorder (ADHD).The physician reviewer found the individual psychophysiological therapy with psychotherapy services provided from 10/31/14 through 12/9/14 was not likely to be more beneficial for treatment of the patients medical condition than other modalities. A review of the medical literature reveals a lack of clinical evidence to support the efficacy of biofeedback interventions in this clinical setting. In the absence of adequate clinical evidence in the peer-reviewed literature that supports the efficacy of neurofeedback therapy, it is not possible to conclude that neurofeedback therapy is likely to be more beneficial than standard therapies available in this setting. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 62-year-old female enrollee has requested authorization and coverage for rizatriptan 5 mg, ODT tablets, #12 per month. The Health Insurer has denied this request indicating that the requested medication quantity is not medically necessary for treatment of the enrollees chronic migraines. The physician reviewer found that The medical records provided for review indicates a diagnosis of migraine headache. Peer-reviewed publications have demonstrated that rizatriptan is effective for abortive treatment of migraine headaches. The records from the provider indicate that no other therapy has been effective. With documented diagnosis of migraine and proven effectiveness of the requested quantity, rizatriptan 5 mg, ODT tablets, #12 per month is supported as medically necessary for treatment of this patients migraines. Based on the foregoing discussion, the requested medication quantity 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 32-year-old male enrollee has requested reimbursement for residential treatment center (RTC) services provided from 6/11/17 through 7/2/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health issues. The physician reviewer found that the medical records provided for review do not support the medical necessity of the RTC services provided from 6/11/17 through 7/2/17 for treatment of this patients behavioral health issues. On 5/27/17 admission, the patients symptoms prevented him from functioning properly. However, by 6/11/17, the patient was not an imminent danger to self or others, and he was not gravely disabled. He was performing his activities of daily living independently. He continued to endorse passive suicidal ideation without intent, as well as anxiety and depression. He continued to report auditory and visual hallucinations, which the records suggest are the patients baseline. His psychotic symptoms were stabilized on Clozaril 500 mg, which had been titrated up from 300 mg. Further, Clozaril titration does not require a RTC setting and can be performed in the outpatient setting. His other medications were unchanged, and he was compliant. His family and girlfriend provided a safe and supportive environment. He no longer required 24-hour monitoring in the RTC setting, and could have continued treatment at IOP level of care. Thus, the RTC services provided from 6/11/17 through 7/2/17 were not medically necessary. Based on the foregoing discussion, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 31-year-old male enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine, cervical spine, and pelvis. The Health Insurer has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees back and neck pain. The physician reviewer found that the records provided for review do not support the medical necessity of the requested MRI studies. The physical examination on 5/16/18 does not detail which muscles are weak or hypotonic. In addition, the neurological examination was limited and the note of prior physical therapy does not include details as to duration, evaluation or outcome. Moreover, there are no laboratory values in the chart to support an indication for an inflammatory process such as sacroiliitis. All told, there is a lack of documentation supporting the medical necessity for MRI of the lumbar spine, cervical spine, and pelvis for evaluation of this patients medical condition. Based on the foregoing discussion, the requested services are not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 59-year-old female enrollee has requested reimbursement for Afirma Gene Expression Classifier assay performed on 10/12/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees thyroid nodule. The physician reviewer found that a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma Gene Expression Classifier assay utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration 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.  Therefore, Afirma Gene Expression Classifier assay performed on 10/12/15 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: Upheld

Summary Reviewer 2

A 56-year-old male enrollee has requested reimbursement and prospective authorization and coverage for J1602, Simponi 50 mg, injected monthly for one year from 9/20/18 forward. The Health Insurer has denied this request indicating that the medication at issue was and is considered investigational for treatment of the enrollees autoimmune hearing loss. The physician reviewer found that this patient has a history of autoimmune hearing loss. He has been treated with steroids and other agents. The patients provider recommended Simponi, an anti-tumor necrosis factor (TNF) agent. Anti-TNF agents have been tried in autoimmune hearing loss as an intratympanic injection in two very small studies by Derebery and colleagues and Van Wijk and colleagues. There was no control group and no randomization in either of the two studies. At this time, there is a lack of evidence demonstrating that Simponi has an effect on autoimmune hearing loss. In sum, J1602, Simponi 50 mg, injected monthly for one year from 9/20/18 forward was not and is not likely to be of greater benefit than other treatment options. Based upon the information set forth above, the medication at issue was not and 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: Medical Necessity
Decision: Upheld

Summary Reviewer 3

A 59-year-old female enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 5/10/18. 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 melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 5/10/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 58-year-old female who presented to her provider on 2/04/21 because of chronic knee pain.  The patient has requested reimbursement for an MRI performed on 2/12/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that MRI is the most optimal means to evaluate an internal derangement. Plain x-rays are of only limited value. The American College of Radiology (ACR) has established aAppropriateness Criteriaa to help referring practitioners in the most efficient and efficacious use of imaging for various clinical presentations. Several variants are described. The first is titled aChronic knee pain. Initial imaginga, and in that variant, MRI is felt to be not appropriate, but it recommends plain x-rays. However, the following three variants describe chronic knee pain when the initial knee x-ray is negative or when it is positive for multiple x-ray abnormalities. In each of these variants, MRI is felt to be ausually appropriatea. In other words, regardless of the plain x-ray findings, an MRI may be worthwhile. The reason that plain x-rays are of only limited value is that the menisci and ligaments are not visible on plain x-rays. One can assess the degree of degenerative disease and whether there are any acute bony structural abnormalities, but this information is only of limited interest in this patient. One can assume that she does not have a fracture, and whether or not she has degenerative change has no bearing. The Health Insurer contends that the patient should have had documentation of various physical examination maneuvers to justify the MRI. The patient was seen by a sports medicine practitioner. An experienced sports medicine practitioner should be able to assess the need for an MRI and potential surgical correction on clinical grounds. In this patient, she had knee symptoms for at least two months and already had physical therapy and conservative management. There is sufficient support for the services at issue in this setting. Therefore, the MRI performed on 2/12/21 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 10/21/15. 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 the breast tomosynthesis performed on 10/21/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of peer-reviewed literature that supports the use of digital breast tomosynthesis compared to currently available techniques. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in peer-reviewed literature. Accordingly, the breast tomosynthesis performed on 10/21/15 was not likely to provide this patient with an improved health outcome when compared to standard available techniques. 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 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 melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. The test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing performed on 12/06/17 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 65-year-old female enrollee has requested authorization and coverage for proton beam radiation therapy. 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 compared to standard radiotherapy with photon IMRT, the benefit of proton therapy is that with its Bragg Peak, radiation dose is deposited more precisely on its target. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. The medical records support proton beam radiation therapy in this patients case, given the significant prior dose her adjacent normal tissue was exposed to from her radiation therapy in 1987. Radiation techniques at that time were much more crude, with little normal tissue sparing. Critical structures that likely received near full tolerance dose for this patient include the brainstem, spinal cord, carotid artery, and cranial nerves. Additionally, her jaw would be at risk for osteoradionecrosis with another full dose of radiotherapy. Thus, the requested proton beam radiation therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 59-year-old male enrollee has requested reimbursement for gene testing performed on 3/9/15. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found that the Afirma gene expression classifier testing performed on 3/9/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The biopsy result was consistent with follicular neoplasm. The median risk of malignancy on follicular neoplasm lesions is 15-30% (Cibas, et al). The Bethesda System recommends a second fine needle aspiration when the cytopathology is consistent with follicular neoplasm. The 2015 American Thyroid Associations guidelines state Diagnostic surgical excision is the long-established standard of care for the management of [follicular neoplasm/suspicious for follicular neoplasm] FN/SFN cytology nodules. However, after consideration of clinical and sonographic features, molecular testing may be used to supplement malignancy risk assessment data in lieu of proceeding directly with surgery. Informed patient preference and feasibility should be considered in clinical decision-making (Haugen, et al).  Fine needle aspiration with molecular testing is considered standard of care in this clinical setting. When the genetic test is suspicious for malignancy, the risk of malignancy increases to 40%, therefore surgery is recommended. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing (Haugen, et al; Alexander, et al). The test was important for the medical decision making to proceed with surgery (Alexander, et al). A benign results would have prevented unnecessary surgery. 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 2


A 61-year-old male enrollee has requested reimbursement for physical therapy services performed from 8/27/15 through 12/5/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee, who has a history of low back pain, knee pain and bilateral arm numbness. The physician reviewer found that there is sufficient support in the efficacy for the treatment modalities in this clinical setting. The care provided was reported as leading to functional improvement, not as a single application of one modality (cupping), but as being complementary to manual therapy, massage and myofascial release therapies. The providers choice to include cupping in the treatment plan was to increase blood flow, soften scarring and improve circulation leading to reduced pain and to increased function was an appropriate plan of care given the reported chronicity of the patients condition and the addressed functional deficits found upon clinical evaluation. All told, the physical therapy services provided between 8/27/15 and 12/5/15 were likely to have been more effective than the other standard options for treatment of this patient. Therefore, for the reasons stated above, the services at issue were likely to have been 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 1

A 28-year-old female enrollee has requested authorization and coverage for ReActiv8 implantable peripheral nerve stimulation. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition.  At issue is whether the requested device is likely to be more beneficial for treatment of the enrollee's condition than any available standard therapy. The physician reviewer found that Neuromodulation has efficacy for post-laminectomy syndrome. Spinal cord stimulation has traditionally been offered in the neuromodulation space, but peripheral nerve stimulation offers a less invasive treatment option. Peripheral nerve stimulation is a minimally invasive, nondestructive treatment option for low back pain that is primarily axial. In patients who have tried conservative care, including a multimodal treatment approach, peripheral nerve stimulation is a minimally invasive treatment option. The current medical evidence supports the requested device in this clinical setting. Therefore, ReActiv8 implantable peripheral nerve stimulation is likely to be more beneficial for treatment of the patientas medical condition than any available standard therapy.