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

Summary Reviewer 1 
 
A 19-year-old female enrollee has requested reimbursement for a Papanicolaou (Pap) smear 
performed on 1/03/22. 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 cervical cancer screening with Pap smear testing is a preventative measure 
included in a routine well-women examination. Per current medical care and American College 
of Obstetricians and Gynecologists (ACOG) guidelines, screening is typically initiated at age 21. In 
this clinical scenario, the patient was 19 years old on the date of service in dispute. Per the 
standard of care, it would have been appropriate for the provider to defer screening until age 21, 
as per the guidelines. Therefore, the Pap smear performed on 1/03/22 was not likely to have 
been more beneficial for evaluation of the patient than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 56-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis performed on 7/29/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollees risk for breast cancer. The physician reviewer found that Tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital breast tomosynthesis performed on 7/29/16 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the 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: Upheld

Summary Reviewer 2

A 49-year-old male enrollee has requested reimbursement for the DecisionDx-Melanoma assay provided on 2/14/17. 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 gene 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 gene assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma assay provided on 2/14/17 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: Overturned

Summary Reviewer 1

An 80-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire airway stimulation. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrolleeas medical condition.The physician reviewer found that this patient has obstructive sleep apnea and has no significant nasal obstruction. The drug-induced sleep endoscopy showed no concentric collapse at velum and primarily anterior posterior collapse at the oropharynx. The patient has not been able to tolerate the continuous positive airway pressure (CPAP) device. The Inspire device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of obstructive sleep apnea. At this point, the patient is a candidate for the Inspire device given the intolerance to CPAP, anterior posterior collapse at the oropharynx, and body mass index and apnea-hypopnea index within FDA criteria. Therefore, hypoglossal nerve stimulation or Inspire airway stimulation is likely to be more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 46-year-old female who has been diagnosed with metastatic signet ring cell adenosarcoma. The patient was initially diagnosed in November 2016. She is currently being treated with folinic acid, fluorouracil and oxaliplatin (FOLFOX) chemotherapy. Prior therapies have included bilateral ureteral stenting, folinic acid fluorouracil and irinotecan (FOLFIRI) and paclitaxel with ramucirumab. Based on a molecular profiling performed with FoundationOne testing, the provider recommended treatment with Cabometyx. The Health Insurer denied the request for coverage and authorization on the basis that the requested Cabometyx 60 mg is not medically necessary for the treatment of this patients medical condition. This denial is the subject of this appeal and determination. There is a lack of support for the requested medication in this clinical setting. Cabometyx (cabozantinib) is not U.S. Food and Drug Administration approved for the treatment of gastric cancer. Off-label use is not supported by major drug compendia or the National Comprehensive Cancer Network guidelines. In addition, the medical literature does not reveal clinical trials that support the use of cabozantinib for patients who are diagnosed with gastric cancer. As such, the efficacy of Cabometyx 60 mg for treatment of this patients medical condition has not been established. Therefore, for the reasons stated above, Cabometyx 60 mg is 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 41-year-old male enrollee has requested reimbursement for intravenous immunoglobulin provided from 4/24/15 through 5/01/15 and 8/07/15 through 8/14/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees medical condition. The physician reviewer found the efficacy of intravenous immunoglobulin has been proven in Guillain-Barre syndrome, chronic inflammatory demyelinating polyradiculoneuropathy, multifocal mononeuropathy, acute exacerbations of myasthenia gravis, short-term treatment of severe myasthenia gravis, and some paraneoplastic neuropathies.  This patient has been diagnosed with polyneuropathy.  Clinical examination does not describe neuropathy features such as distal weakness or reflex loss. Nerve conduction velocities were mildly slowed, consistent with demyelination, but there was no evidence of conduction block reported.  There was no distal latency prolongation, increased temporal dispersion, or delayed or absent F waves reported.  Per the submitted documentation, this patient does not meet published criteria for CIDP, which indicate that the diagnosis rests upon a combination of clinical, electrodiagnostic and laboratory features with exclusions to eliminate other disorders that may appear as CIDP.  There is a lack of support for the services at issue in this clinical setting.  All told, intravenous immunoglobulin provided from 4/24/15 through 5/01/15 and 8/07/15 through 8/14/15 was not medically indicated 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 43-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/8/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who was asymptomatic as to her breasts. The physician reviewer found that the patient is a 43-year-old female who was asymptomatic with respect to her breasts.  Her immediate breast history dates back to 4/3/15 when she had a screening mammogram that demonstrated a suspicious nodule in the right breast.  After the 4/3/15 mammogram, she was recalled for additional imaging including compression views on 5/5/15, and the nodule persisted.  Following the 5/5/15 study, it was recommended that a sonogram be performed.  The results of the sonogram were not submitted. She returned on 8/8/16 for a screening mammogram, and no significant abnormalities were detected.  The 8/8/16 study consisted of a combination two dimensional and three dimensional tomosynthesis study. This study was compared to prior mammograms. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breast tissue was described as containing scattered fibroglandular elements. The Health Insurer denied reimbursement noting that the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there was an abnormality on her mammograms in 2015 that warranted further attention.  It is unclear what the outcome was after those evaluations, but since no mention was made of a biopsy, it is reasonable to conclude that the sonogram revealed either nothing, or more likely, a cyst.  In either of those two settings, it is not unreasonable to perform a tomosynthesis as a follow-up study.  As mentioned above, tomosynthesis offers the advantage of separating out overlapping structures and can better delineate the margins of a suspected mass or cyst.  As this is the first follow-up after detection of a mass, digital breast tomosynthesis performed on 8/8/16 was more likely to have been more effective 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 3

A 60-year-old male enrollee has requested reimbursement for Oncotype testing performed on 4/25/19. 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 once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features, such as the grade of tumor and prostate-specific antigen level. This helps guide the most appropriate therapy for patients taking into account their age and comorbidities because many patients will not require therapy (i.e. surgery or radiation) and may be followed closely instead. The important features to recognize are Gleason score and prostate-specific antigen, but these are imperfect. At this time, current biomarkers are inadequate for risk stratification, and better prognostic biomarkers are needed. Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score. This assay may help identify patients with low risk disease that could be followed rather than referred for surgery. Oncotype DX may better stratify such patients with localized disease. Thus, Oncotype DX testing performed on 4/25/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 45-year-old female enrollee has requested reimbursement for FoundationOne CDx testing performed on 1/29/19. 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 FoundationOne CDx assay is a molecular assay that explores the mutations and other alterations of several hundred genes in an individuals cancer cells. The hope is that the assay will identify a target at which a chemotherapeutic agent could be directed for clinical benefit. Thus far, however, there is a lack of convincing evidence that the assay identifies useful targets often enough to be clinically beneficial. A randomized trial by Le Tourneau and colleagues did not demonstrate that picking a drug using such an assay was superior to picking a drug based on the oncologists judgment. Marquart and colleagues demonstrated that only a small minority of patients might benefit from using the assay to pick their therapy. Therefore, FoundationOne CDx testing performed on 1/29/19 was not likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 51-year-old male has requested reimbursement for gene expression profiling performed on 5/04/17. 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 there is a lack of support for the services at issue in this patients case. There is a lack of evidence from the literature that tailored follow-up according to these test results has an impact on long-term outcomes. Prospective randomized studies to determine recurrence risk is lacking for this test. The medical evidence has not determined the superior efficacy of the services at issue. Thus, gene expression profiling performed on 5/04/17 was 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: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 47-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C.  The physician reviewer found 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  The current medical evidence supports the requested medication in this clinical setting.  All told, 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

The parent of a 16-year-old male enrollee has requested reimbursement for Prometheus Anser IFX diagnostic testing performed on 12/13/13. The Health Insurer has denied this request indicating that the testing at issue was investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the Prometheus Anser IFX diagnostic testing performed on 12/13/13 was likely to be more effective for this patient than other available treatment options. Anser IFX testing is commonly used in gastroenterology practices and has been well studied. There is sufficient peer-review literature supporting its usefulness in treating patients with irritable bowel syndrome and guiding therapy. Prometheus Anser IFX testing informs the provider if the serum levels of drug are in the range to be beneficial and effective or if they have antibodies that could potentially lead to a reaction or failure to respond. This helps guide the provider in dosing or may lead to discontinuation of the drug if the patient is not likely to benefit from the medication. All told, 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: Upheld

Summary Reviewer 

The patient is a 62-year-old female with a medical history including alcoholism, depression and anxiety who presented to the emergency department with an altered mental status after reportedly overdosing on medications. She was brought in by EMS with reports of taking Valium, Codeine and propranolol. At the time of presentation, her blood pressure and respiratory rate were stable. The physician reviewer found that at the time of admission, the patient was hemodynamically stable, afebrile with normal oxygen saturations on room air. She was diagnosed with an intentional overdose at the time of admission although psychiatry determined that she did not require a hold due to denial of intention to harm herself. She did not have any significant cardiac arrhythmias or electrolyte disturbances. She was stable for discharge within two days of admission. The inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patientas signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting, when the
patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. In this case, the patient was admitted in stable condition and could have been treated at a lower level of care. Therefore, acute inpatient services provided from 8/24/20 through 8/26/20 were not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 19-year-old male enrollee has requested reimbursement for procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20. 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 this patient had symptoms concerning for inflammatory bowel disease, and has a diagnosis of ulcerative colitis. He was taking azathioprine, a therapy with significant potential adverse effects, and biologic therapy, which has serious potential adverse effects, was being contemplated.  Therefore, definitive diagnosis of inflammatory bowel disease was necessary in this case.  However, the American Gastroenterological Association guidelines and the American College of Gastroenterology guidelines for ulcerative colitis do not recommend the use of anti-Saccharomyces cerevisiae antibody (ASCA, CPT 86671) and anti-neutrophil cytoplasmic antibody (ANCA, CPT 86021) testing, or any other antibody testing, for diagnosis or management of ulcerative colitis. The American College of Gastroenterology guidelines specifically state that apooled sensitivity of antibody testing for diagnosis of ulcerative colitis is low, and such markers are not used for establishing or ruling out a diagnosis of ulcerative colitis.a American College of Gastroenterology guidelines for Crohnas disease do not recommend the tests either. Therefore, procedure codes 86671 x 2 and 86021 x 3 performed on 2/14/20 were not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 45-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found 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 should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  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: Upheld

Summary Reviewer 2 
 
A 64-year-old male insured has requested reimbursement for laboratory testing performed on 
5/13/22. The Health Insurer has denied this request indicating that the services at issue were 
considered investigational for evaluation of the insureds acute deep vein thrombosis (DVT). The 
physician reviewer found that deep vein thrombosis and pulmonary embolism may be caused by 
hereditary  thrombophilias.  The  increased  risk  is  worth  knowing  especially  in  situations  of 
prolonged immobility such as surgery, long car trips, or long airplane flights. These complications 
may be prevented by appropriate interventions and the avoidance of certain drugs which are 
prothrombic.  There  are  several  known  genetic  factors  that  can  cause  thrombophilia.  The 
G20210A mutation increases risk of deep vein thrombosis about three-fold but nearly 20-fold in 
compound  heterozygous  patients  with  Factor  V  Leiden.  Similarly,  patients  with 
hyperhomocysteinemia and Factor V Leiden are at increased risk for deep vein thrombosis. In 
this case, the patient underwent Factor V Leiden genetic testing, which was likely to be more 
beneficial than an activated Protein C resistance assay, which is complicated and can result in 
spurious results (Kadauke, et al.; Exner, et al.). Thus, the genetic testing performed in this 
patients work-up for hypercoagulable states was appropriate. All told, the laboratory testing 
performed on 5/13/22 was likely to be more beneficial for evaluation of the patients medical 
condition than any available standard therapy.