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

Summary Reviewer 2

A 43-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 7/11/15.  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 that Tomosynthesis provides advantages to radiologists in the interpretation of digital mammography. Tomosynthesis allows for the separation of dense glandular elements from underlying mass/architectural distortion especially in cases of heterogeneously dense tissue, such as in this case. This often results in a decrease in callbacks and increase in detection of small cancer. For these reasons the addition of tomosynthesis to the usual two-dimensional (2D) views was likely of greater benefit to the patient than had the exam been done using 2D imaging alone. 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 

A 60-year-old male enrollee has requested authorization and coverage for Genium Ottobock X3 waterproof microprocessor knee system. The Health Insurer has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found that the Genium Ottobock X3 waterproof microprocessor knee system is medically necessary for treatment of the patients medical condition. Sawers and Hafner conducted a systematic review of outcomes associated with microprocessor controlled knees (MPK), such as the Genium X3, in comparison to non-microprocessor controlled knees, (NMPK), such as the Endolite hydraulic knee the patient currently has. In regards to the microprocessor controlled knees, the authors state This technology is intended to make the prosthetic knee responsive to the user's instantaneous needs (i.e., allow him or her to change cadence and walking speed) and adjust its behavior (i.e., provide more or less knee-flexion resistance) in response to extrinsic conditions, thereby mimicking the behavior of a nondisabled knee. The authors conclude that Moderate evidence exists to suggest that swing and stance MPKs are associated with increased confidence during ambulation, increased self-reported mobility, reduced self-reported cognitive demand while walking, improved self-reported well-being, and equivalent overall societal costs when compared with NMPKs. The Genium X3 provides swing and stance control and conveys these benefits. In addition, Kannenberg and colleagues performed a systematic review of MPKs in limited community ambulators, a population typically thought to be inappropriate for these devices. The authors state Clinical research, mainly conducted in the unlimited community ambulator (MFCL-3) population with low to moderate methodological quality, has demonstrated improved safety and superior function of MP-controlled prosthetic knees (MPKs) in level walking, walking on uneven terrain, walking on slopes, walking on stairs, and stumble recovery, resulting in significantly reduced numbers of stumbles and falls and improved balance than with NMPKs. In this case, the patient is beyond the K3 (MFCL-3) functional level. The patient is a K4 level ambulator. The authors conclude that, The results of this systematic review suggest that the use of MP hydraulic stance only or MP stance and swing control prosthetic knees may improve safety, function, and mobility of limited community ambulators with unilateral [transfemoral amputation] TFA. In light of these findings, it no longer appears appropriate to generally withhold this advanced prosthetic technology from MFCL-2 individuals. Given the above, the MPK Genium X3 is medically necessary for the high functioning K4 level patient who requires a waterproof knee. Thus, the requested device is medically necessary to maximize the patients function, health, and overall well-being.
Therefore, the requested device 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 patient is a 64-year-old male with a diagnosis of hypogonadism. His symptoms include decreased energy and libido, mood swings, sleepiness and changes in fat/muscles. His pre-treatment testosterone level was 208 in 2011. The patient has been treated with testosterone injections and Testopel. The patient is requesting reimbursement for Testopel implants provided on 1/21/16 and 5/26/16. The Health Insurer has denied this request as investigational. The use of Testopel is appropriate only for patients with an appropriate diagnosis of hypogonadism based on criteria recommended by national and international guidelines. Guidelines require measurement of two morning testosterone levels along with follicle-stimulating hormone/luteinizing hormone (FSH/LH) levels prior to initiation of therapy to identify the presence of and type of hypogonadism. In this case, the documentation submitted for review does not support that this was performed. In addition, patients who are on testosterone replacement should be monitored with laboratory work-up that includes testosterone, hematocrit, prostate-specific antigen (PSA), and lipid profile initially at frequent intervals and annually thereafter. Based on the clinical documentation submitted for review, the Testopel implants provided on 1/21/16 and 5/26/16 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 3

A 63-year-old male enrollee has requested reimbursement for CPT 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19. 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 this patient has a history of severe post-traumatic arthritis of the right wrist 20 years post fracture. Anterior interosseous neurectomy and posterior interosseous neurectomies are wrist denervation surgical procedures which are well-documented to relieve wrist pain due to arthritis, as in this case. Partial wrist denervation is a useful palliative procedure for chronic wrist pain when other surgical procedures are not possible or desirable. Per the medical literature, this procedure can be performed through small incisions and is known to provide pain relief in this setting. Thus, CPT code 64999 (unlisted procedure, nervous system, right wrist anterior and posterior interosseous neurectomy) performed on 6/10/19 was likely to have been more beneficial for treatment of the patientas medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 47-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma assay performed on 12/15/17. 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 submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had 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 12/15/17 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.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 45-year-old female enrollee has requested reimbursement for a sleep study performed on 12/11/14. The Health Insurer has denied this request indicating that the service at issue was not medically necessary for evaluation of the enrollees sleep disorder. The physician reviewer found in cases of mild OSA, home tests are occasionally noted to underestimate the severity of the medical condition rather than overestimate it.  In this case, the patient was reported to have been diagnosed with OSA via a home sleep test and was started on a CPAP machine. The CPAP was causing the patient more problems. In such cases, an attended polysomnography/sleep study would be warranted to determine the etiology of this paradoxical occurrence. In this patients case, the attended polysomnography/sleep study was medically necessary to assist in evaluating whether or not the patient had OSA. The medical literature indicates that the application of a CPAP machine, in some patients who do not have OSA, can lead to the development of central apneas. Ultimately, in this patients case, the performance of the attended polysomnography/sleep study provided findings/results that led to an improvement in the clients medical condition. By determining that she did not have OSA, the patient would no longer need to use the CPAP machine which had been exacerbating her respiratory issues during the day.  As a result, the service at issue was medically appropriate. Therefore, for the reasons stated above, the service at issue was medically necessary for the evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1
A 27-year-old female enrollee has requested authorization and coverage for proton beam therapy for six weeks. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that the medical literature does not support the superior efficacy of proton beam therapy over standard therapy in this clinical setting.  In the most recent version of the National Comprehensive Cancer Network guidelines, it does not address proton therapy for breast cancer, as they do for some other sites such as lung cancer.  Proton therapy can be used for select patients with unique anatomic considerations. However, the documentation provided does not demonstrate that other radiation techniques would be unacceptable and/or that proton therapy would yield a clinically meaningful advantage over conventional radiation and/or intensity modulated radiation therapy in this patient with a right-sided breast cancer. While there are studies describing its use in breast cancer, this modality is not an accepted standard of care. For this patient, proton beam therapy for six weeks is not likely to be more effective than the standard options for treatment of this patient. Therefore, for the reasons stated above, the requested services are not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 63-year-old female enrollee has requested reimbursement for computed tomography (CT) of the head or brain and computed tomography angiography (CTA) of the head and neck performed on 4/29/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees medical condition. The physician reviewer found the submitted documentation supports the services at issue in this clinical setting.  This patient had episodes of acute neurologic dysfunction.  Her differential diagnosis included stroke or dissection, and imaging was carried out to assess these possibilities.  Imaging such as CT and MRI allow for distinction between hemorrhagic and ischemic strokes, providing greater certainty whether to administer thrombolysis.  Imaging in this circumstance of acute transient neurologic dysfunction appropriately included brain and neurovascular imaging.  CT of the head or brain and CTA of the head and neck were appropriate testing in this clinical setting, as it appears that MRI-MRA were not completed due to claustrophobia.  In sum, CT of the head or brain and CTA of the head and neck performed on 4/29/15 were medically indicated for the evaluation of this patient.  Therefore, the services at issue were medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 56-year-old female enrollee has requested reimbursement for a blood test performed on 11/24/18. 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 American College of Gastroenterology guidelines for dyspepsia support the use of Helicobacter pylori testing for evaluation of symptoms. The current medical literature supports the use of Helicobacter pylori testing to check for this infection as a cause for pain. Although alternative tests are available, a negative antibody test can rule out Helicobacter pylori infection as a cause for symptoms. In this case, in which the patient reported prior infection, the Helicobacter pylori antibody test can rapidly eliminate Helicobacter pylori infection as a cause for symptoms if negative, and establish the need for additional testing if positive. For these reasons, the blood test performed on 11/24/18 was likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 67-year-old male enrollee has requested reimbursement for gene testing performed on 4/19/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees metastatic renal cell carcinoma. The physician reviewer found that metastatic renal cell cancer is resistant to conventional chemotherapy. The provider ordered somatic cancer mutational testing in an effort to decide the next best therapy. Patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Von Hoff and colleagues performed a study of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. In this patients case, VHL, MTOR mutations and CDKN2A/B loss were notable aberrations. This does suggest targeted therapy with an mTOR inhibitor may be utilized. Everolimus is an inhibitor of the mammalian target of rapamycin (mTOR) kinase, and placebo controlled clinical trials support its use in renal cell carcinoma. There is sufficient support for the services at issue in this clinical setting. Thus, gene testing performed on 4/19/16 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: Experimental
Decision: Upheld

Summary Reviewer 1


A 50-year-old male has requested reimbursement for Anser IFX testing performed on 4/15/15.  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 Anser IFX was likely to have provided additional information for the management of this patients biologic therapy.  If it was determined that the patient had fibrosis at the anastomosis leading to periodic small bowel obstruction, then surgery may have been advised.  Postoperatively, the patient needed to be put on a biologic.  There is sufficient support for the services at issue in this clinical setting.  All told, Anser IFX testing performed on 4/15/15 was likely to have been more efficacious than other methods of evaluating this patient.  Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 52-year-old female who presented with a left cheek basal cell cancer. The patient has requested authorization and coverage for brachytherapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. The physician reviewer found that guidelines do endorse the use of brachytherapy in the treatment of skin cancer. Brachytherapy uses a radioactive isotope to deliver therapeutic radiation near or inside the tumor target. In lesions on the face, due to the unique conformality of brachytherapy, there would be less scatter radiation to other nearby facial structures compared to other conventional radiation techniques using external beam radiation therapy. Brachytherapy would allow lower doses to the oral cavity and eye compared to standard techniques. Furthermore, in this case, brachytherapy may be preferentially used to allow for appropriate tumor coverage while allowing for normal tissue sparing. There is sufficient support for the requested services in this clinical setting. Therefore, brachytherapy is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 33-year-old female enrollee has requested reimbursement for exome sequence analysis (81415) provided on 8/15/19. 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 the Society for Maternal-Fetal Medicine indicates that routine use of prenatal sequencing as a diagnostic test is not currently supported due to insufficient validation data and knowledge about its benefits and pitfalls. Although the technology is promising in genetic evaluation of an anomalous fetus, many challenges remain for the routine clinical use of exome sequencing. Interpreting results from exome sequencing is a very lengthy process, and is challenging due to reliance on phenotypic data that may be incomplete. Additionally, there are many counseling and ethical issues related to prenatal exome sequencing, including determining when to report secondary or incidental findings, the ongoing need for reanalysis of results, and the challenges of interpreting results in meaningful ways for patients. Therefore, given the complexities involved in interpretation of results, timeliness of results, and patient/family counseling, the decision to proceed with this type of testing should be made in consultation with a provider specializing in genetic testing, such as a certified genetic counselor or medical geneticist and is currently not the standard of care or medically necessary as in this case. Thus, CPT 81415 (exome sequence analysis) performed on 8/15/19 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 29-year-old female enrollee has requested reimbursement for the laboratory testing (CPT 86038, 86644, 82728, 82746, 82784, 85682, 84480, 84479, 80061, 82607, 36415, 86665, 86664, 83540, 83550, 80074, 86645, 86663, 82306, 84481, 80050, 86039, 81261, 81264, 81342, 81340, 84999, and 86790) provided on 8/16/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees body aches, low grade fever and fatigue. The physician reviewer found that according to the records provided for review, this patient presented with nerve tingling, headaches, muscle spasms, fatigue and body aches. The constellation of symptoms does not suggest the requested testing strategy was indicated for diagnosis of this patients medical condition. Specifically, the patient did not meet the standard clinical scenario for the evaluation of a lymphoproliferative disorder (Styczynski, et al; Ok, et al). Therefore, the laboratory testing (CPT 86038, 86644, 82728, 82746, 82784, 85682, 84480, 84479, 80061, 82607, 36415, 86665, 86664, 83540, 83550, 80074, 86645, 86663, 82306, 84481, 80050, 86039, 81261, 81264, 81342, 81340, 84999, and 86790) provided on 8/16/17 was not medically necessary for evaluation of the patients medical condition. Based on the foregoing discussion, the services at issue were not medically necessary for evaluation of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 55-year-old male enrollee has requested reimbursement for epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that the patient has a history of lower back pain. Per the records, he has tried and failed conservative treatment, including physical therapy and pain medications, including Norco. The patient reported bilateral leg numbness and pain. Magnetic resonance imaging (MRI) findings showed severe central stenosis at L4-L5, with right-sided severe foraminal stenosis and moderate foraminal stenosis on the left. There was also possible mass effect on the left L4 and L5 nerve roots. The patient underwent lumbar transforaminal epidural steroid injections on 2/02/16 and 2/18/16. There is support for the services at issue in this clinical setting. Epidural steroid injections for lumbar radiculopathy and spinal stenosis is a widely accepted treatment for chronic lower back pain and radicular symptoms for patients that have failed conservative treatment options and/or patients that have undergone spine surgery and still have chronic back pain due to scar tissue and stenosis. In sum, epidural injections of corticosteroid preparations (e.g., Depo-Medrol) with or without added anesthetic agents on 2/02/16 and 2/18/16 were likely to have been more beneficial than other treatment options.