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

Summary Reviewer 

A 65-year-old female enrollee has requested authorization and coverage for Prolia. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Fractures are the most dangerous aspect of osteoporosis and 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 for patients who have failed or are intolerant to other available osteoporosis therapy. Therefore, Prolia is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a three-year-old female who was transported by air ambulance from Childrens Hospital in Centennial, Colorado (CHCC) to Childrens Hospital in Millard, Nebraska (CHMC) on 6/30/15. The patient was born with a congenital diaphragmatic hernia on 1/29/15. She was intubated at birth. The patient underwent several surgeries. She remained with severe pulmonary hypertension. Multiple attempts to wean the child from the ventilator failed. It was determined that the patient no longer required the services of a level IV neonatal intensive care unit (NICU). The decision was made to transfer the patient to a level III NICU in Nebraska to be closer to her home. The ambulance was scheduled in advance on 6/29/15. The transport was initiated on 6/30/15, and no adverse events occurred during transport. The Health Insurer has denied reimbursement for air ambulance services provided on 6/30/15. Per the Health Insurer, the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.  Air ambulance services are considered medically necessary under certain circumstances. These circumstances include: the patients condition is such that any other means of transport would be medically contraindicated, the patients condition is such that the time necessary for transport by land poses a threat to the patients health, and the patient is transported to the nearest hospital with appropriate facilities for treatment. All of these criteria must be met in order for air ambulance transport to be medically necessary. In this case, the patient was being transferred from a level IV NICU to a level III NICU, a lower level of care. This transfer was planned in advance, not completed emergently. The patient was transferred to another state in order to be closer to home. There are other NICU facilities closer to CHCC than CHMC. All told, air ambulance services provided on 6/30/15 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 1

A 63-year-old female enrollee has requested reimbursement for unlisted laboratory services provided on 7/02/19 and 1/28/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeas medical condition. The physician reviewer found that ClonoSEQ assay is a very sensitive genetic assay that can detect very minimal numbers of residual myeloma cells. It is used often in clinical trial situations to determine the efficacy of treatment. Munshi and colleagues performed a meta-analysis, and the assay has been shown to correlate with both progression-free survival and overall survival. It is becoming more commonly used to accurately guide therapy. The National Comprehensive Cancer Network recommends its use. Therefore, unlisted laboratory services provided on 7/02/19 and 1/28/20 were likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 64-year-old female enrollee has requested reimbursement for collagen crosslinks testing performed on 11/18/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees osteoporosis. The physician reviewer found that Biochemical markers provide a dynamic view of the remodeling process, which covers rate of turnover and pathogenesis, and should improve fracture risk prediction. Furthermore, biochemical markers can be used to monitor the short-term effects of therapy, and indicate if an excessive slowing of the remodeling process is occurring. Suppression of biochemical markers of bone turnover after three to six months of treatment and biochemical marker increases after one to three months of anabolic therapy have been predictive of greater bone mineral density responses and fracture risk reduction in large clinical trials. In this case, the patient had recently started a new anabolic agent. The information derived from collagen crosslinks can be used to determine whether the therapy is working and whether the patient is compliant with therapy. Thus, collagen crosslinks testing performed on 11/18/17 was 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: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 41-year-old male. Notes dated 10/27/21 reported that the patient presented to the 
hospital on 9/18/21 with acute hypoxemic respiratory failure and sepsis in the setting of COVID-
19  pneumonia. The patient has requested reimbursement for LTACH days from 11/11/21 through 
11/13/21. The Health Insurer has denied this request and reported the services at issue were not 
medically necessary for the treatment of this patient. This denial is the subject of this appeal and 
determination. The physician reviewer found that the submitted documentation supports the 
medical necessity of the services at issue. In this case, the patient remained at a very high aspiration 
risk, highlighted by his witnessed  aspiration event  on 11/11/21. It is not uncommon for patients 
to fail tracheostomy decannulation in the LTACH setting, as they are at high risk for mucous 
impaction and aspiration in the days following decannulation. The LTACH screened the patient 
for transfer to a lower level of service, the skilled nursing facility (SNF) setting. Regardless of the 
timing of when the patient was accepted to the SNF versus when he was transferred to SNF, the 
patient continued to receive medically necessary LTACH care, including aggressive mucous 
clearance and pulmonary hygiene. By 11/13/21, the patients providers had observed him for three 
days following tracheostomy  tube removal and felt more comfortable transferring the patient to 
the SNF, where less aggressive respiratory support would be available to the patient. Therefore, 
LTACH days from 11/11/21 through 11/13/21 were medically necessary for the treatment of this 
patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 59-year-old female enrollee has requested reimbursement for the Veracyte Afirma genetic testing provided on 12/3/14. 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 as this patients initial biopsy report reported suspicious findings but the lesion was not malignant. This was a major determining factor in delineating further course of action. Genetic testing with the Veracyte Afirma was indicated in this case as standard protocol on the fine needle aspirate from this patients thyroid nodule. The findings helped the provider direct treatment and the patient was able to avoid unnecessary surgery. Given the current medical literature, the Veracyte Afirma genetic testing performed on 12/3/14 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, I have determined 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 48-year-old female has requested reimbursement for procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees melanoma. The physician reviewer found that the 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 to 1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggest 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 the DecisionDx-Melanoma test has not made it part of routine analysis after sentinel lymph node biopsy. There has 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, procedure codes 84999 (DecisionDx-Melanoma) and 99000 performed on 1/25/17 were not likely to have been more effective than other available methods of evaluating this patient. 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 62-year-old male enrollee has requested authorization and coverage for insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator. 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 submitted documentation supports the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Hypoglossal nerve stimulator has been demonstrated to be safe and effective in a small subset of patients with obstructive sleep apnea who have failed continuous positive airway pressure, have nonconcentric airway collapse, an apnea-hypopnea index between 20 and 50, and a body mass index less than 32. This procedure has been approved by the U.S. Food and Drug Administration. With a body mass index of 26.6, apnea-hypopnea index of 19.3 and nonconcentric airway collapse, this patient meets the criteria. He has failed continuous positive airway pressure therapy, which is the gold standard treatment for obstructive sleep apnea. Thus, insertion of chest wall respiratory sensor electrode or electrode array, including connection to pulse generator is likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 44-year-old female enrollee has requested reimbursement for Prometheus testing performed on 4/30/15.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition. The physician reviewer found there are a number of reasons why patients can develop worsening symptoms while on maintenance therapy with a tumor necrosis factor inhibitor.  The patients inflammatory pathway may have escaped the influence of tumor necrosis factor.  The patient may have the presence of antibodies resulting in below therapeutic levels of the anti-tumor necrosis factor agent.  The possibility of Clostridium difficile and other enteric infections also needs to be considered.  However, measuring drug levels and their antibodies is problematic.  The target drug level for any patient is unknown, and it is likely that the tissue level of drug rather than serum level is most important. Additionally, antibody detection is imprecise. Antibodies are often transient and may not be biologically meaningful in vivo.  In sum, the services at issue were not likely to have been of greater benefit than other methods of evaluating this patient.  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: Experimental
Decision: Upheld

Summary Reviewer 2

A 51-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma Assay (CPT code 84999 - unlisted chemistry procedure) provided on 1/17/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay provided on 1/17/17 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 2


A 41-year-old male has requested authorization and coverage for the LINX procedure.  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 current medical evidence has not demonstrated the superior efficacy of the requested services in this patients case.  The medical records document gastroesophageal reflux disease as based on pH recording. However, it appears he has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs. Also, implantation of LINX in this clinical setting must be approached with caution given his documented complaints of dysphagia and probable eosinophilic esophagitis.  In sum, the requested LINX procedure is not likely to be more efficacious than other treatment options.  Based upon the information set forth above, the requested services are 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  
The patient is a 66-year-old male who has requested reimbursement for magnetic resonance 
imaging (MRI) of the pelvis performed on 11/08/21. The patient has requested reimbursement for 
MRI of the pelvis provided on 11/08/21. 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 the submitted 
documentation fails to demonstrate the medical necessity of the services at issue. Based on the 
clinical records, the patient had a normal PSA after antibiotic treatment and normal PSA density. 
Performing an MRI would not be considered a clinically appropriate or generally accepted 
standard for management of this patients medical condition. The current medical literature does 
not support utility of MRI in patients with a normal PSA and PSA density. Therefore, the MRI of 
the pelvis provided on 11/08/21 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 65-year-old male enrollee has requested reimbursement for gene testing provided on 9/26/18. 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 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 as either class 1 or 2, with class 2 melanomas having a significantly higher rate of recurrence than class 1. Gerami reported on 217 cases, with good correlation between prognosis and DecisionDx-Melanoma class, in patients who have undergone sentinel node biopsy. Berger reported on 156 cases, but there was insufficient follow-up to determine the real value of the assay. It is not clear how the five-year DecisionDx-Melanoma data compares to the ten-year Balch data. Most importantly, it is not clear if the DecisionDx-Melanoma assay can be used to make clinical decisions. Therefore, gene testing provided on 9/26/18 was not likely to have been superior over other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 45-year-old male enrollee has requested authorization and coverage for powered upper extremity range of motion assist device, elbow, wrist, hand and finger. The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrolleeas medical condition.  The physician reviewer found that there is a lack of support for the requested device in this clinical setting. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve his hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase his participation in bimanual activities. Winstein and colleagues reviewed the various treatments of motor dysfunction after a stroke. The authors noted that a Cochrane review found that upper limb robotic therapy provided some benefit with regard to activities of daily living and arm function, but not arm muscle strength. The guidelines indicate that these studies were noted to have numerous limitations. These limitations include the variation within the trials with regard to duration and amount of training, the specific devices used, and patient populations studied limit the interpretation of these results. McCabe and colleagues performed a small study that was retrospective with inconsistent timing of testing and limited interpretation. The authors discussed the feasibility and clinical experience of using myoelectric orthosis in rehabilitation of chronic stroke patients. The study used a small patient group and indicated that additional studies are warranted to determine the effectiveness of these methods in the clinical setting. Additional controlled studies of the MyoPro Orthosis for upper extremity paralysis after a stroke are needed with larger patient groups, consistent improvements of relevant outcome functional measures, and long-term follow-up. Therefore, the requested powered upper extremity range of motion assist device, elbow, wrist, hand and finger is not likely to be more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 38-year-old male enrollee has requested authorization and coverage for a cardioverter defibrillator. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollee, who has cardiac sarcoidosis. The physician reviewer found that this patient has a history of cardiac sarcoidosis and symptomatic 2:1 atrioventricular block in need of pacemaker placement. In this circumstance of cardiac sarcoidosis and ejection fraction greater than 35% with an indication for pacemaker placement, it is reasonable to implant a defibrillator if meaningful survival of greater than one year is expected. Some patients with cardiac sarcoidosis with normal ejection fraction and no heart failure symptoms have high arrhythmic event rates, especially when late gadolinium enhancement is identified on cardiac MRI or abnormal findings are seen on cardiac PET imaging, such as this patient. The medical evidence supports the requested device in this case. Therefore, the requested cardioverter defibrillator is likely to be of greater benefit 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 55-year-old male has requested reimbursement for high-intensity focused ultrasound performed on 8/14/17. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees prostate cancer. The physician reviewer found that high-intensity focused ultrasound is an evolving technology in the prostate cancer treatment armamentarium. While the minimally invasive nature makes high-intensity focused ultrasound ablation a readily accessible tool, its role in initial therapy of moderate risk disease as monotherapy shows no benefit and potential risk over standard treatment protocols at this time. In sum, high-intensity focused ultrasound performed on 8/14/17 was not likely to have been of greater benefit than other treatment options. 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.