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

Summary Reviewer  
The patient is a 54-year-old female with a history of non-allergic rhinitis, previously diagnosed 
nasal  septal  deviation,  asthma  and  recurrent  acute  sinusitis.  The  patient  has  requested 
authorization and coverage for computed tomography (CT) scan of the sinuses. The physician 
reviewer found that the current medical literature supports the requested CT scan of the sinuses 
in this case. The American Academy of Allergy, Asthma and Immunology (AAAAI) Practice 
Parameters for the management of sinusitis discusses that if a patient fails antibiotics and other 
adjunctive  measures  such  as  inflammation  control  with  systemic  steroids,  nasal  sprays 
(azelastine and fluticasone) and Singulair, a sinus CT would be indicated. This patient also has 
progressive sinus disease that has affected her ability to smell and does not have positive skin 
testing to indicate that allergies would be the main driving factor for her recurrent inflammation. 
She also does have documented septal deviation which could contribute to her rhinitis and 
sinusitis. In addition, the Rhinitis 2020 AAAAI practice parameter update does consider symptoms 
including facial pain, pressure, decreased sense of smell and post-nasal drainage to be an 
indication for sinus CT. Therefore, the requested CT scan of the sinuses is medically necessary for 
the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 42-year-old female enrollee has requested reimbursement for the digital breast tomosynthesis provided on 1/19/16. 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 the breast tomosynthesis performed on 1/19/16 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two dimensional (2D) and three dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 57-year-old male enrollee has requested reimbursement for automated nerve conduction testing during anterior cervical discectomy and fusion performed on 10/20/15.  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 patient underwent intraoperative neurophysiological monitoring during multiple level anterior cervical discectomy and fusion in the presence of myelopathy. Intraoperative neurophysiological monitoring during surgery is recommended when such procedures have a risk of significant complications that can be detected and prevented through use of neurophysiological monitoring. Intraoperative monitoring of somatosensory evoked potentials and transcranial electrical motor evoked potentials in procedures that involve the spinal cord itself can predict adverse surgical outcomes in complex cases. However, the evidence-based guidelines do not recommend intraoperative electromyography (EMG) and nerve conduction velocity monitoring on peripheral nerves during cervical spine surgery. An abnormal EMG response during the surgical procedure may or may not be associated with a clinically significant injury (Resnick, et al). Therefore, intraoperative electromyography is not recommended. In sum, intraoperative EMG and nerve conduction velocity monitoring on peripheral nerves during surgery is not recommended. In sum, the somatosensory and motor evoked potentials were medically necessary; however, the intraoperative electromyography and neuromuscular junction testing has not been substantiated. Therefore, a portion of the services at issue were medically necessary for treatment of the patients medical condition. The Health Insurers denial should be partially overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 60-year-old female enrollee has requested authorization and coverage for bronchoscopic thermoplasty. The Health Insurer has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees moderate to severe persistent asthma. The physician reviewer found that currently, the three initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. Cox and colleagues reported that patients with moderate to severe asthma demonstrated improved control at one-year follow-up following treatment with bronchial thermoplasty. Further, Pavord and colleagues found short-term worsening in symptoms, but evidence of improved long-term control of asthma with the procedure. Finally, the Castro and colleagues compared bronchial thermoplasty with a sham procedure and followed the patients for one year. The authors noted that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. Overall, the data supports the short- and long-term benefits of bronchial thermoplasty for well selected patients. This patient has undergone a thorough evaluation and is on an aggressive regimen. However, her symptoms have persisted despite her current medical therapy and she has continuously required systemic steroids. Given these findings, the requested bronchoscopic thermoplasty is supported as medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the requested procedure is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 65-year-old male enrollee has requested authorization and coverage for PET (CPT code 78813) scan. The Health Insurer has denied this request indicating that the requested testing considered investigational for evaluation of the enrollees prostate cancer. The physician reviewer found that a recent trial assessed the impact of PET (Axumin) scans on patients with a biochemical recurrence. It found that 61.2% of patients had a change in management as a result of the scan and the trial was stopped early. Of the changes, 40% required a change in radiation fields, and 35% underwent systemic therapy instead of radiotherapy (ASCO GU 2018). Recent medical literature have come to similar conclusions that PET scans can affect treatment after a prostatectomy (Wallitt, et al; Jani, et al). As such, PET (CPT code 78813) scan is likely to be of greater benefit when compared to the available conventional modalities for the management of this patients medical condition. Therefore, for the reasons stated above, the requested services are 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 

A 68-year-old male enrollee has requested reimbursement for DecisionDx-Melanoma testing performed on 10/03/18 and 10/16/18. The Health Insurer has denied this request and reported that the service at issue were not medically necessary for the evaluation of the enrollees medical condition. The physician reviewer found that this patient had several early stage melanomas. The National Comprehensive Cancer Network guidelines state 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. Newer prognostic molecular techniques should not replace standard staging procedures. In addition, there is a lack of definitive data regarding its use for risk classification in patients with cutaneous melanoma. This test does not currently have a role in determining which patients are candidates for adjuvant immunotherapy, either as a standard of care or as part of clinical trials. Therefore, DecisionDx-Melanoma testing provided on 10/03/18 and 10/16/18 was not medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 48-year-old female enrollee has requested reimbursement for Oncotype DX Colon Cancer Assay performed on 4/28/16.  The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees colon cancer. The physician reviewer found there is sufficient support for the services at issue in this clinical setting.  It has been established that adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer.  It is much more controversial as to its value in stage II colon cancer, as in this patients case.  Most oncologists have made this decision based on specific pathologic features, such as a poorly differentiated histology, lymphovascular invasion, or presentation with obstruction or perforation.  Another approach is with the use of genetic panels.  The Oncotype DX Colon Cancer Assay is a 12-gene panel that predicts the risk of recurrence of the cancer in both stage II and III colon cancer.  This assay appears to predict the risk of recurrence with accuracy beyond what could be predicted from these usual pathologic features.  The medical evidence supports the use of Oncotype DX Colon Cancer Assay in assessing the potential value of adjuvant chemotherapy.  Therefore, Oncotype DX Colon Cancer Assay performed on 4/28/16 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: Upheld

Summary Reviewer 


A 48-year-old female enrollee has requested reimbursement for genetic testing performed on 5/25/17. The Health Insurer has denied this request indicating that the services at issue were not medically necessary for evaluation of the enrollees breast cancer. The physician reviewer found that understanding the molecular drivers of cancer progression and metastases is an area of ongoing and active research, predominantly driven by the goal of identifying specific genomic aberrations that may ultimately result in individualized cancer treatment. In addition to likely providing prognostic information, the value of next generation sequencing (NGS) to predict candidates for specific mutation-driven treatment holds promise, but is not yet ready for routine clinical use.  Although the ability to decipher genomic aberrations in individual breast cancers to the single nucleotide resolution is now possible, there is a lack of data to show that this information can guide treatment decisions for patients with metastatic breast cancer. The use of NGS, such as with FoundationOne testing, continues to be the subject of ongoing clinical trials, and use outside of a clinical trial at this time is not reasonable or medically necessary. In addition, this patient still has treatment options available to her, such as TDM-1. Thus, genetic testing performed on 5/25/17 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: Experimental
Decision: Overturned

Summary Reviewer 3

A 62-year-old female enrollee has requested reimbursement for FoundationOne CDx test performed on 12/31/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrolleeAaas medical condition. The physician reviewer found that the The therapy of advanced NSCLC has been revolutionized by the finding of EGFR mutations in certain adenocarcinomas. Even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of NSCLC has significantly expanded in recent years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations that was analyzed in the patient in question is for mutually exclusive somatic driver mutations. Patients on targeted therapy may develop resistance to erlotinib and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. There is sufficient support for the services at issue in this clinical setting. Therefore, FoundationOne CDx test performed on 12/31/19 was likely to have been more beneficial than other available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3 
A 60-year-old male enrollee has requested reimbursement for CPT 81529, which is an oncology 
(cutaneous melanoma, mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 
content and three housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm 
reported as recurrence risk including likelihood of sentinel lymph node metastasis, on 3/8/22. 
The  Health  Insurer  has  denied  this  request  and  reported  that  the  service  at  issue  was 
investigational for the evaluation of the enrollees melanoma. The physician reviewer found that 
the American Academy of Dermatologys clinical guidelines for melanoma note that routine 
molecular testing, including GEP, for prognostication is discouraged until better use criteria are 
defined. The guidelines further note that the application of molecular information for clinical 
management, such as informing on sentinel lymph node eligibility, follow-up, and/or therapeutic 
choices,  is  not recommended  outside  of a  clinical  study or trial.  The NCCN  guidelines on 
cutaneous melanoma note that the use of GEP testing according to specific American Joint 
Committee on Cancer (AJCC)-8 melanoma staging, before or after sentinel lymph node biopsy, 
requires  further  prospective  investigation  in  large,  contemporary  data  sets  of  unselected 
patients, and that prognostic GEP testing to differentiate melanomas at low versus high risk for 
metastasis should not replace pathologic staging procedures. The NCCN further notes that there 
is a low probability of metastasis in stage I melanoma and a higher proportion of false-positive 
results,  and  that  GEP  testing  should  not  guide  clinical  decision-making  in  this  subgroup.  Therefore, CPT 81529, which is an oncology (cutaneous melanoma, mRNA, gene expression 
profiling by real-time RT-PCR of 31 genes (28 content and three housekeeping), utilizing formalin-
fixed paraffin-embedded tissue, algorithm reported as recurrence risk including likelihood of 
sentinel lymph node metastasis, on 3/8/22, was not likely to have been more beneficial for 
evaluation of the patients condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 51-year-old male enrollee has requested reimbursement for DecisionDX testing provided on 10/6/14. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees uveal melanoma.  The physician reviewer found choroidal melanoma is a relatively rare tumor which has consequences on both vision and lifespan. Metastatic disease prediction has been difficult and little data has been available to providers to educate the patient and to aid in the type and frequency of tests to order to follow the disease. With the DecisionDX assay the provider has a tool at their disposal to help predict the likelihood of metastatic disease and accordingly prescribe adjuvant therapy. The DecisionDX also helps provide a feasible schedule for the frequency of metastatic disease testing via laboratory and imaging studies. Given this support, the DecisionDX testing provided on 10/6/14 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: Medical Necessity
Decision: Upheld

Summary Reviewer 

The patient is a 61-year-old male with a history of hypothyroidism on escalating doses of levothyroxine.  The patient has requested reimbursement for the ultrasound of the soft tissues of head and neck performed on 1/12/21. 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 Hypothyroidism affects up to 5% of the general population, with a further estimated 5% being undiagnosed. Hypothyroidism is diagnosed biochemically, being overt primary hypothyroidism defined as serum thyroid stimulating hormone (TSH) concentrations above and thyroxine concentrations below the normal reference range. Although studies have demonstrated that patients diagnosed with hyperthyroidism, thyroiditis, goiter, and adenoma had significantly elevated risks of differentiated thyroid cancer, there does not appear to be an association between a history of hypothyroidism and risk of thyroid cancer. Thyroid ultrasonography is not indicated as part of routine workup of hypothyroidism. Therefore, the ultrasound of the soft tissues of head and neck performed on 1/12/21 was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a five-year-old male who has been diagnosed with disorder of dysregulated anger and aggression of early childhood, combined, proactive and reactive aggression. The patientas parent has requested reimbursement for intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. The physician reviewer found that the Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. In terms of risk of harm, the records support a score of 3. The patient had a significant risk of harm, due to impulsivity, self-harm, and aggression. With regard to functional status, the records support a score of 3. The patient had moderate functional impairment, due to conflict with parents and other adults as well as peers, and recent expulsion from school. Gains were made in the context of a structured setting. In terms of comorbidity, the records support a score of 1. There were no developmental or medical issues. With regard to level of stress of the recovery environment, the records support a score of 2. The patient had a mildly stressful environment, due to expulsion from school. In terms of environmental support, the records support a score of 2 due to his parentsa attempts to participate in treatment, with some struggles to manage the patientas behavior and medications at home. In terms of resiliency and treatment history, the records support a score of 4. The records indicate poor resiliency and/or response to treatment, due to a lack of response to previous intensive treatment, and his current turmoil and difficulty making progress toward developmentally appropriate behaviors. With regard to treatment and acceptance of the parents, the records support a score of 2 due to their participation in treatment. Thus, the patient had a total score of 17. This recommended level of care is high-intensity community-based services. An intensive outpatient program, such as the one the patient was attending, is consistent with this level of care. Furthermore, a program specializing in young children was needed for the patient. Therefore, intensive outpatient mental health treatment for children and adolescents provided from 7/15/19 through 7/31/19 was medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 58-year-old female enrollee has requested reimbursement for MammaPrint testing performed on 1/21/14. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for the evaluation of the enrollees breast cancer. The physician reviewer found there are several established biomarkers that are prognostically valuable in breast cancer. These include the presence of estrogen or progesterone receptors, HER2 amplification, as well as proliferative index, and histologic grade. Newer technologies such as gene expression such as the MammaPrint may also classify tumors to basal-like or luminal-type of disease. MammaPrint is U.S. Food and Drug Administration (FDA) approved and has been validated in different clinical trials. In this case, the patient was provided with adjuvant chemotherapy based on her high risk MammaPrint profile. Based on available medical evidence and medical literature, MammaPrint was likely to be more beneficial for evaluation of the patients medical condition than other modalities. 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: Experimental
Decision: Overturned

Summary Reviewer 1


A 36-year-old female enrollee has requested reimbursement for Botox injections received on 10/14/14.  The Health Insurer has denied this request indicating that the services at issue were investigational for treatment of the enrollees medical condition. The physician reviewer found review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. The documentation submitted for review documents the patient has chronic migraine. In addition, the patient has failed at least two classes of preventive agents. Botox is standard therapy for treatment of chronic migraine, and has been shown to be as effective or more effective, than medications available to treat chronic migraine. In addition, Botox is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic migraine. For the reasons provided, the Botox injections at issue were 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 likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.