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

Summary Reviewer 2

A 63-year-old male enrollee has requested reimbursement for the wearable cardioverter defibrillator provided on 11/5/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees medical condition. The physician reviewer found that circumstance there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (>90 days) where continued left ventricular dysfunction (ejection fraction = 35%) is documented to persist in spite of appropriate treatment (Russo, et al).  A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. A prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explantation. In sum, the wearable defibrillator has not yet been demonstrated by existing scientific literature as 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: Upheld

Summary Reviewer 1 
 
A 24-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing 
performed on 7/06/21. 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 use of gene expression profiling (GEP) testing according to specific 
American Joint Committee on Cancer (AJCC) melanoma stage requires further prospective 
investigation in large, contemporary datasets of unselected patients. Prognostic GEP testing to 
differentiate melanomas at low versus high risk for metastasis should not replace pathologic 
staging procedures. Moreover, since there is a low probability of metastasis in stage I (T1) 
melanoma and a higher proportion of false-positive results, GEP testing should not guide clinical 
decision-making in this subgroup. The current medical evidence has not established the superior 
efficacy of the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma testing 
performed on 7/06/21 was not likely to have been more beneficial than any available standard 
therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2
A 42-year-old female enrollee requested authorization and coverage for CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation). 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 minimally invasive therapies to treat symptoms of uterine myomas can be effective alternatives to major surgery. Such modalities include pharmacologic agents, uterine artery embolization, magnetic resonance-guided focused ultrasound, and laparoscopic radiofrequency ablation, known as the Acessa procedure. Acessa is used to treat women with symptomatic myomas and was approved by the U.S. Food and Drug Administration in 2012. Brucker and colleagues compared the mean hospital discharge times and perioperative outcomes for radiofrequency volumetric thermal ablation of fibroids and laparoscopic myomectomy. The authors noted, Radiofrequency volumetric thermal ablation resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than laparoscopic myomectomy. Lin and colleagues performed a meta-analysis of eight studies. The authors assessed the short-term and long-term symptom relief and quality of life improvement, procedure-related adverse event rate, reintervention rate, and days missed from work after laparoscopic radiofrequency ablation. The authors noted, All subscales of quality of life improved significantly, and most of the changes remained stable in long-term follow-up. In conclusion, laparoscopic radiofrequency ablation therapy Acessa is an efficacious way to treat small-sized and nonpedunculated symptomatic uterine fibroids, providing stable long-term symptom relief and quality of life improvement. Therefore, CPT 58674 (Acessa procedure - laparoscopic radiofrequency ablation) is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 43-year-old female enrollee has requested authorization and coverage for left arthroscopy, hip surgical with femoroplasty (treatment of cam lesion), left arthroscopy, hip surgical with acetabuloplasty (treatment of pincer lesion). The Health Insurer has denied this request and reported that the requested services are not medically necessary for treatment of the enrollees hip pain. The physician reviewer found that the submitted documentation supports the medical necessity of the requested services in this clinical setting. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improves outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. In this case, the patient presents with an approximate one-year history of constant and progressively worsening left hip and groin pain. Significant functional limitations are noted in activities of daily living. Clinical examination findings have been consistent with radiographic and imaging evidence of a left hip femoroacetabular impingement with cam and pincer lesions. She has failed over six months of conservative treatment, including activity modification, anti-inflammatory medications, and physical therapy. X-rays findings document no signs of joint space narrowing, and are reportedly consistent with Tonnis grade 0. Current evidence-based medical guidelines and peer-reviewed literature support surgical management of femoroacetabular impingement syndrome when non-surgical treatment methods fail and specific criteria have been met. The medical evidence supports the requested services in this clinical setting. All told, the requested left arthroscopy, hip surgical with femoroplasty (treatment of cam lesion), left arthroscopy, hip surgical with acetabuloplasty (treatment of pincer lesion) are medically necessary 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: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 64-year-old female who was diagnosed with rectal cancer in 2016. This patient has localized (T3N0M0) squamous cell cancer of the rectum. The patients provider sent a sample tissue for molecular testing which was initiated on 2/28/17. The patient has requested reimbursement for CarisMI profile testing services performed on 3/10/17.  The Health Insurer denied this request as investigational for the evaluation of this patients medical condition. Molecular profiling, also known as next generation sequencing (NGS) is not considered a standard of care for the treatment of recurrent or locally progressive anal carcinoma. Its use is not endorsed by the National Network Cancer guidelines. Immunotherapy is used for salvage therapy and studies show a benefit from both nivolumab and pembrolizumab. PD-L1 overexpression should not be used to select patients for treatments targeting the PD-1 pathway as studies have shown benefit even in those with no expression. NGS would not have been more beneficial for treatment decision making for this patient. As such, CarisMI profile testing services performed on 3/10/17 was not likely to have been of greater benefit than any available standard of care.  Therefore, for the reasons stated 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 2


A 63-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 6/11/15. 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 the breast tomosynthesis at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Additionally in this case, the tomographic images were particularly helpful in resolving the left breast asymmetry as normal tissues, which was the lesion in question. Based on the support in the medical literature and the clinical documentation submitted for review, the use of breast tomosynthesis 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 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 3


A 61-year-old male enrollee has requested authorization and coverage for percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device).  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 the submitted documentation supports the requested services in this clinical setting.  The left atrial appendage occlusion device (Watchman) has been approved to reduce the risk of thromboembolism from the left atrial appendage in patients with non-valvular atrial fibrillation, who are at increased risk for stroke and are recommended for anticoagulation therapy.  There is sufficient support for the requested services in this patients case.  Many patients with atrial fibrillation take warfarin or other blood thinning medicines to prevent a stroke caused by a blood clot in the brain. However, warfarin can increase the risk of bleeding anywhere in the body.  If bleeding happens in the brain, this can also cause a stroke.  In this patients case, the requested percutaneous transcatheter closure of the left atrial appendage with implant (Watchman device) is likely to be more effective than other treatment options.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 59-year-old female enrollee has requested authorization and coverage for Prolia (denosumab) injections. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees osteoporosis. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Osteoporosis is an increasingly widespread condition. Fractures are the most dangerous aspect of osteoporosis. Fractures can lead to acute and chronic pain. A newer medication, denosumab (Prolia), is a fully human monoclonal antibody which has been approved for the treatment of osteoporosis, treatment-induced bone loss, bone metastases, multiple myeloma, and giant cell tumor of bone. Prolia is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy.  This patient is unable to tolerate Reclast therapy. The requested medication is medically appropriate in this clinical setting. Thus, Prolia (denosumab) injections are medically necessary 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 57-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 9/01/16.  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 there is sufficient support for the service at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Therefore, digital breast tomosynthesis performed on 9/01/16 was likely to have been of greater benefit than other methods of evaluating this patient.  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 2

A 34-year-old female enrollee has requested authorization and coverage for BRCA testing. The Health Insurer has denied this request indicating that the requested testing is considered investigational for evaluation of the enrollees risk of breast cancer. The physician reviewer found the request for BRCA genetic testing is likely to be more effective for this patient than other available treatment options. The patient meets National Comprehensive Cancer Network (NCCN) guidelines for BRCA testing given that she has more than two relatives on the same side of the family with breast cancer. If she were to harbor a BRCA mutation then prophylactic surgeries or heightened screening could be pursued to lower her risk of breast and/or cervical cancer. As such, BRCA genetic testing is clinically indicated and 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 requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 50-year-old female enrollee has requested reimbursement for the injection of periurethral bulking agent provided on 12/19/14. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees recurrent stress urinary incontinence and intrinsic urethral sphincter deficiency.   The physician reviewer found that the injection of coaptite for urinary stress incontinence is an acceptable treatment for urinary stress incontinence in well selected patients. The procedure can be performed under local anesthesia and there is usually an immediate improvement in the patients stress incontinence. Although there are other viable treatment options, this procedure is likely to be more beneficial. Thus, the injection of periurethral bulking agent provided on 12/19/14 was 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 service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 34-year-old female enrollee has requested reimbursement for genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees pregnancy. The physician reviewer found that the American College of Obstetricians and Gynecologists (ACOG) recommends that all patients be screened for cystic fibrosis and SMA. However, the ACOG states that fragile X testing is only indicated for patients with a family history of fragile X-related disorders or intellectual disability suggestive of fragile X syndrome and who are considering pregnancy or are currently pregnant or if a woman has unexplained ovarian insufficiency or failure or an elevated follicle-stimulating hormone level before age 40 years, fragile X carrier screening is recommended to determine whether she has an FMR1. Based on these guidelines, the genetic testing for fragile X syndrome (CPT code 81423) provided on 6/28/17 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 1

A 68-year-old female enrollee has requested reimbursement for carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees vulvar atrophy. The physician reviewer found Vulvovaginal atrophy with symptomatic vaginal dryness and dyspareunia is treated with non-hormonal vaginal moisturizers and lubricants as first-line treatment. If these therapies do not provide adequate symptom relief, estrogen therapy is used. Laser treatment is available for potential treatment of vulvovaginal atrophy with urinary incontinence, as in this case. The Mona Lisa laser technology, as used in this case, delivers carbon dioxide laser energy to the vaginal wall tissue with multiple treatment sessions over a specific period of time. Current literature supports that laser therapy is promising. However, laser devices have not been approved by the U.S. Food and Administration for the treatment of vulvovaginal atrophy. Further, the American College of Obstetricians and Gynecologists has advised that although initial observational data indicate potential utility, additional data from randomized trials are needed to further assess the efficacy and safety of this procedure in treating vulvovaginal atrophy, particularly for long-term benefit. Therefore, the carbon dioxide laser surgery (Mona Lisa Touch Laser) provided on 9/12/17 and 11/3/17 were 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 1

A 62-year-old male enrollee has requested reimbursement for testing for liver disease provided on 6/11/19. 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 FibroTest and FibroSure are identical proprietary tests marketed under different names in Europe and America, respectively. ActiTest is a modification of FibroTest. The tests have primarily been studied in patients with hepatitis B and C. FibroTest involves assessment of alpha-2-macroglobulin, alpha-2-globulin, gamma globulin, apolipoprotein A1, and total bilirubin. It also takes into account the patients age and sex. Results from the individual assays are combined and are used to classify patients having mild fibrosis (F0 to F1), significant fibrosis (F2 to F4), or an indeterminate stage of fibrosis. The sensitivity for detection of significant fibrosis is approximately 60 to 75 percent, and the specificity is approximately 80 to 90 percent. In clinical practice, the services at issue are used routinely in patients with hepatitis B. Therefore, testing for liver disease (FibroTest-ActiTest/HCV-FibroSure) provided on 6/11/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1


A 32-year-old female enrollee has requested authorization and coverage for Enbrel. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees ankylosing spondylitis. The physician reviewer found that Enbrel is an anti-tumor necrosis factor (TNF) medication used to treat inflammatory arthritis. The available medical records do not contain documentation of active arthritis. There is a lack of evidence of synovitis on physical examination and there is no record of symptomatology consistent with inflammatory lower back pain or inflammatory peripheral joint disease. There is no radiographic documentation of inflammatory arthritis of the spine or peripheral joints. On the basis of this lack of documentation, the request for Enbrel 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.