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

Summary Reviewer 2
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 regarding the request for Reactiv8 device, the requesting provider has indicated that this device has a novel treatment approach when compared with peripheral nerve stimulation. It is stated that this device is intended to treat multifidus muscle atrophy to improve instability and axial low back pain. Deckers and colleagues noted, aElectrical stimulation to elicit episodic lumbar multifidus contraction is a new treatment option for chronic mechanical low back pain. Results demonstrate clinically important, statistically significant, and lasting improvement in pain, disability, and quality of life.a Per Mitchell and colleagues, aIn participants with disabling intractable chronic low back pain who receive long-term restorative neurostimulation, treatment satisfaction remains high and improvements in pain, disability, and quality of life are clinically meaningful and durable through four years.a Per Thomson and colleagues, among the 37 patients completing two-year follow-up, numerical rating scale (NRS) pain scores improved, Oswestry Disability Index (ODI) scores improved, and health-related quality of life improved. The authors noted, a57% of patients experienced a greater than 50% reduction in pain, and 51% of patients benefited by a greater than 15-point reduction in ODI, both substantial improvements.a As such, there are multiple studies that support the safety and efficacy of this treatment. In this case, the patient is noted to have tried physical therapy, epidural injections, spinal cord stimulation, and sacroiliac joint injections. The patient has also failed medication treatment. As such, there is a lack of remaining treatment options to address the patientas pain. Therefore, ReActiv8 implantable peripheral nerve stimulation is likely to be more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


An 18-year-old male enrollee has requested reimbursement and prospective authorization and coverage for mental health residential services provided from 11/23/14 through discharge and forward. The Health Insurer has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition. The physician reviewer found the mental health residential services provided from 11/23/14 through discharge and forward were not and are not medically necessary for treatment of the patients medical condition. The patient does not meet the medical necessity criteria for residential level of care.  He is at low risk of self-harm. He was noted only once to have suicidal thoughts, and even then did not have a plan or intent.  His medical problems were stabilized, and he was continued on the same two psychotropic medications at the same dosage throughout his stay. He had moderate interference with addiction recovery, and moderate impairment in social functioning. Based on all of these factors and carefully considering American Society of Addiction Medicine (ASAM) placement criteria, residential level of care was not medically necessary in this clinical setting. The patient could have been safely and effectively managed at a lower level of care. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the services at issue were not and are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 57-year-old male enrollee has requested authorization and coverage for implanted upper airway stimulation device (Inspire). The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees obstructive sleep apnea (OSA). The physician reviewer found that the request for implanted upper airway stimulation device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is some medical literature indicating that hypoglossal nerve stimulation for treatment of obstructive sleep apnea may have beneficial outcome with minimal adverse effect for selected patients. However, there are a lack of studies comparing data regarding outcomes of hypoglossal nerve stimulation to that of standard available therapy. Although the use of hypoglossal nerve stimulation for the treatment of obstructive sleep apnea is promising, the available medical literature is limited. Given the lack of definitive support in the peer-reviewed literature, implanted upper airway stimulation device (Inspire) is not likely to be more beneficial for treatment of the patients medical condition than standard available therapy. Based upon the information set forth above, the requested device 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: Experimental
Decision: Upheld

Summary Reviewer 3

A 55-year-old female enrollee has requested reimbursement for DecisionDX-melanoma laboratory testing performed on 5/13/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees malignant melanoma. The physician reviewer found that the diagnostic test DecisionDX melanoma test is considered experimental. The test, using retrospective data, helps determine the risk of recurrence for early melanoma. The test lacks therapeutic implications as there is limited published data to support using adjuvant therapy in early stage I and II melanoma (lymph node negative) regardless of risk of recurrence. Furthermore, prospective randomized data for determination of risk of recurrence is lacking for this test. The scientific evidence does not support the superior efficacy of this test over standard options available for evaluation of patients in this clinical setting. Moreover, there is a lack of evidence that this technology improves the net health outcome.  As such, the DecisionDX-melanoma laboratory testing performed on 5/13/16 was not likely to have been more efficacious than other options available for evaluation of this patients medical condition. Therefore, for the reasons stated above, the services at issue were not likely to have been 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 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 patient has eosinophilic esophagitis. It appears that he is having symptomatic improvement with proton pump inhibitor therapy, consistent with the condition of proton pump inhibitor responsive esophageal eosinophilia.  His heartburn and regurgitation respond to proton pump inhibitor therapy as well. There is a lack of literature supporting anti-reflux surgery as a treatment for eosinophilia of the esophagus. The mainstay of treatment includes proton pump inhibitor therapy, topical steroid therapy and diet modification with periodic dilation for refractory dysphagia.  The LINX device could exacerbate dysphagia and make clinical management complex.  In sum, the requested LINX procedure is not likely to be superior over 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: Experimental
Decision: Overturned

Summary Reviewer 1

The patient is a 58-year-old male who presented with invasive breast, cT2N1M1, estrogen receptor (ER) positive, progesterone receptor (PR) positive, Her2 negative with a single bone metastases in the right acetabulum. He is being evaluated for stereotactic body radiotherapy (SBRT) for the single bone metastases. The patient has requested authorization and coverage for SBRT. The Health Insurer has denied this request indicating that the requested services are considered investigational. In some cases, patients with certain histologies with limited metastatic disease are considered good candidates for treatment with SBRT (Hanna and Landau; Tree, et al). There is convincing medical evidence that suggests that patients with breast cancer with an oligometastatic presentation benefit from SBRT. This patient has several features that portend a good prognosis for treatment to the oligometastatic site, including the patients age, bone only metastases, and the presence of only a single site of metastatic disease (Wong, et al). Therefore, the requested SBRT is 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 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: Experimental
Decision: Overturned

Summary Reviewer 3


A 62-year-old male enrollee has requested reimbursement for laboratory testing (Fibrotest-Actitest) performed on 8/14/15.  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 the Fibrotest-Actitest is a serum blood test to characterize fibrosis and determine whether cirrhosis is present.  With liver biopsy as the gold standard, Fibrotest has been found to perform well enough to be an effective alternative to biopsy in patients with chronic hepatitis B.  Accordingly, published studies have concluded that Fibrotest-Actitest is an effective alternative to liver biopsy.  In this patient with established cirrhosis, and prior liver biopsy, Fibrotest-Actitest provided a noninvasive alternative to repeating liver biopsy.  For these reasons, laboratory testing performed on 8/14/15 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: Overturned

Summary Reviewer 2

[INSERT FIRST TWO SENTENCES FROM SUMMARY REVIEW DETERMINATION] The physician reviewer found that according to the documentation submitted for review, the patient underwent FNA of three thyroid nodules and the cytopathology of the right dominant nodule was interpreted as AUS with Afirma testing interpreted as benign. The clinical documentation does not demonstrate that a repeat FNA was performed at the time the initial cytopathology came back as AUS. Due to the lack of clinical documentation demonstrating a repeat FNA was performed, the gene testing performed to gauge risk for thyroid cancer on 2/16/17 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 
 
The parent of a one-year-old female enrollee has requested authorization and coverage for a whole 
genome test. The Health Insurer has denied this request and reported that the requested service is 
investigational for the enrollees of the enrollees ataxia. The Health Insurer indicated that the 
requested  service  is  investigational  for  the  evaluation  of  the  enrollees  medical  condition. 
Therefore, the Health Insurer has denied coverage for the requested service. At issue is whether a 
whole genome test is likely to be more beneficial for evaluation of the enrollee's condition than 
any available standard therapy. The physician reviewer found that the American College of Medical 
Genetics and Genomics (ACMG) evidence-based clinical practice guideline, for the use of exome 
and genome sequencing (ES/GS) in the care of pediatric patients with one or more congenital 
anomalies with onset prior to age one year or developmental delay or intellectual disability with 
onset prior to age 18 years, strongly recommends that ES/GS be considered as a first- or second-
tier test for such patients. While this child has ataxia, this practice guideline shows the benefits of 
genome sequencing. Ngo and colleagues report an approximately 50% diagnostic rate for current 
whole-exome sequencing (WES) based methods when evaluating patients with ataxia, suggesting 
that genome sequencing will likely have significant added benefit in identifying genetic etiologies 
for ataxias and other neurodegenerative diseases. Given this child's young age and rapid onset and 
progression of disease, the requested service is warranted to identify a specific diagnosis as quickly 
as possible. Therefore, a whole genome test is likely to be more beneficial for evaluation of the 
patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 40-year-old female enrollee has requested reimbursement for CPT code 31299 performed on 12/22/20. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrolleeas medical condition. The physician reviewer found that the medical evidence does not support the superior efficacy of the services at issue. Kompelli and colleagues performed a systematic review of cryotherapy for the treatment of chronic rhinitis. The authors could not make evidence-based recommendations for the use of cryotherapy due to the weak pool of evidence. Sinno and colleagues performed a systematic review of inferior turbinate reduction techniques and found limited objective data and no evidence of long-term efficacy of cryotherapy. The authors concluded that submucosal resection and radiofrequency ablation were the best techniques for providing long-term resolution of symptoms, preservation of turbinate function, and low complication rates. Mirza and colleagues performed meta-analysis of randomized controlled trials comparing microdebrider- and radiofrequency-assisted turbinate reduction. The authors noted better objective and subjective clinical outcomes among patients who underwent microdebrider-assisted turbinate reduction, particularly at long-term follow-up. Overall, there is insufficient high-quality, peer-reviewed, evidence to support the use of inferior turbinate cryotherapy over other available therapies. Therefore, CPT code 31299 performed on 12/22/20 was not likely to have been more beneficial than other available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 49-year-old female enrollee has requested reimbursement for Guardant 360 provided on 11/01/17. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling, such as with Guardant 360, is reasonable and medically necessary. Therefore, Guardant 360 testing provided on 11/01/17 was medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 70-year-old female enrollee has requested reimbursement for inpatient treatment provided from 5/20/15 through 5/21/15. 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 the medical necessity for inpatient treatment provided from 5/20/15 through 5/21/15 has not been established in this clinical setting. According to Mount, a variety of drugs can raise the serum potassium, primarily by interfering with the renin-angiotensin-aldosterone system (RAAS). The most common are angiotensin inhibitors such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), aldosterone antagonists and other potassium sparing diuretics. In this case, the patient had hyperkalemia due to self-discontinuation of a potassium-wasting diuretic while continuing a RAAS medication. These are reversible causes of hyperkalemia. The patient was effectively treated in the ED. The documentation supports that the patient remained stable and tolerated treatment. The patients potassium level had normalized by 5/20/15 and there were no further indications for acute inpatient hospitalization. Therefore, the inpatient services provided from 5/20/15 through 5/21/15 were not indicated for this patient. Based on the above, 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 2

A 59-year-old female enrollee has requested reimbursement for digital breast tomosynthesis performed on 8/30/16.  The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee, who presented for a breast examination.  The physician reviewer found that the medical literature supports breast tomosynthesis 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 state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed on 8/30/16 was likely to have been superior to other methods of evaluating this patient. Based upon the information set forth above, the service at issue was likely to have been 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 a 17-year-old male enrollee has requested reimbursement for intravenous treatment with antibiotics for Lyme disease from August 2015 through November 2015. 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 there is a lack of support for the services at issue in this patients case.  Per the medical evidence, strictly clinical diagnosis of Lymes disease is not the standard of care in late disease. Early in the course of the disease, serology may be negative.  However, late in the course, serologic testing is indicated.  In general, it is difficult to clinically diagnose a disease with such a wide range and common spectrum of symptoms.  In addition, the standard approach for Lyme disease is oral doxycycline for limited disease and ceftriaxone for central nervous system infection.  The records do not include a cerebrospinal fluid analysis.  In sum, the superior efficacy of the services at issue has not been established.  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 3


A 54-year-old female enrollee has requested authorization and coverage for bronchial thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollees persistent asthma.   The physician reviewer found with regard to this patient, however, there is no indication as to why the patient is not maintained on a combination inhaler or a leukotriene receptor antagonist, both of which are standard of care in asthma and are recommended by current guidelines. The providers notes indicate the patient had been placed on these agents but there is no documentation as to duration and reason for discontinuation. Further, there is no assessment of any associated conditions such as allergic disease, reflux or sinus disease. Further, there is a diagnosis of aspergillosis, a variety of which can worsen asthma control, alluded to in a consult document from April 2016, but nothing more regarding treatment or resolution. There are no records of an eosinophil count or IgE level as well as consideration of using omalizumab or another biologic for control. Given the lack of documentation supporting the requested procedure, the bronchial thermoplasty 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 procedure 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 

A 55-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 1/26/18. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees melanoma. The physician reviewer found that the records document an early stage melanoma. The National Comprehensive Cancer Network guidelines states while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. The results of this testing was not likely to have altered treatment and surveillance recommendations. Thus, DecisionDx-Melanoma assay performed on 1/26/18 was not medically necessary for the evaluation of this patient. Therefore, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.