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

Summary Reviewer 2

A 64-year-old female enrollee has requested authorization and coverage for implantation of a nerve stimulator. The Health Insurer has denied this request indicating that the requested service is considered investigational for treatment of the enrollees moderate obstructive sleep apnea (OSA). The physician reviewer found that in the peer-reviewed medical literature, Certal and colleagues noted that, that hypoglossal nerve stimulation therapy may be considered in selected patients with OSA who fail medical treatment. Further studies comparing hypoglossal nerve stimulation with conventional therapies are needed to definitively evaluate outcomes. In this clinical case, the patient meets some of the criteria for implantation of upper airway stimulation to improve the symptoms. However, the patient has not undergone standard methods of management including improvement of the nasal airway with turbinate reduction and possible nasal septal reconstruction. Although the standard methods have not been shown to improve OSA, they can improve tolerance to nasal CPAP therapy. Additionally, the patient did not present any other physical examination information to decide whether other surgery such as uvulopalatopharyngoplasty or maxillary-mandibular advancement could offer any additional improvement of the symptoms. Accordingly, the requested implantation of a nerve stimulator 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 service 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: Overturned

Summary Reviewer 

The patient is a 38-year-old male who has been found to be at risk for human immunodeficiency virus (HIV) by his clinical team. The patient has requested authorization and coverage for Descovy 200 mg-25 mg tablets. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. In this patientas case, Descovy is medically indicated, given the patientas reaction to Truvada. This patient reported significant nausea, diarrhea and insomnia while on Truvada. Descovy has been approved by the U.S. Food and Drug Administration for HIV prophylaxis in patients at risk. There is sufficient support for the requested medication in this clinical setting. Therefore, Descovy 200 mg-25 mg tablets are medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 63-year-old female enrollee has requested reimbursement for ExoSym kinetic orthosis for right knee provided on 9/12/16. The Health Insurer has denied this request indicating that the device at issue was considered investigational for treatment of the enrollees right knee pain. The physician reviewer found that there is a paucity of high level clinical trials supporting the use of ExoSym kinetic orthosis in treatment of grade 4 arthritic knees. The patients records document that she has exhausted all measures of conservative treatment. In this clinical setting, knee replacement surgery would be indicated. ExoSym kinetic orthosis is not likely to be more beneficial than available standard treatment including total knee arthroplasty. Thus, the ExoSym kinetic orthosis for right knee provided on 9/12/16 was 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 device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer

The patient is a 64-year old female with a history of hypertension, hyperlipidemia and hypothyroidisms. There is reported intolerance to generic beta blocker medication and generic losartan (Cozaar). The patient reported dizziness and headache. The patient has requested authorization and coverage for the brand medication Cozaar. The Health Insurer denied this request and reported that the requested brand medication is not medically necessary for the treatment of the patients medical condition.  This denial is the subject of this appeal and determination. There is a lack of support in the documentation provided for the medical necessity of the requested brand name medication. Based on the records provided, the patient has been diagnosed with hypertension and she reported side effects to some medications. However, the symptoms of headaches and dizziness, in the absence of hypotension, are uncommon side effects to generic losartan medication. In addition, there is a lack of temporal association between the start of the losartan and the symptom onset. The record notes that losartan was started six weeks prior to the reported dizziness and headaches making a causal relationship unlikely. The documentation provided does not demonstrate a significant intolerance to the generic losartan medication.  Moreover, there are additional formulary medications that have not been documented as trialed if a true intolerance to losartan medication were to be demonstrated. In sum, Cozaar has not been demonstrated as medically necessary for treatment of this patients medical condition. Therefore, based on the above, the requested medication is not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 36-year-old female enrollee has requested reimbursement for polymerase chain reaction testing performed on 12/16/18. 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 there is a lack of support for vaginitis panel testing using polymerase chain reaction technology in this patients case. Although these methods have high sensitivity and specificity and a shorter turn-around time than culture, polymerase chain reaction testing offers no proven benefit over standard culture in symptomatic women. Furthermore, there is a lack of evidence on the clinical utility and impact of polymerase chain reaction testing for vaginitis. There is a lack of studies showing that polymerase chain reaction testing leads to better patient management decisions and/or better health outcomes. Studies of diagnostic accuracy alone are inadequate, especially because most symptomatic women can be diagnosed with a standard workup and/or a trial of empiric therapy. Thus, polymerase chain reaction testing performed on 12/16/18 was not likely to have been more effective than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 34-year-old female enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). The Health Insurer has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees major depressive disorder. The physician reviewer found that the requested TMS therapy is not medically necessary for treatment of the patients major depressive disorder. TMS is endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. A typical treatment course of TMS consists of 30 to 40 sessions spanning four to six weeks. According to Perera and colleagues, the standard regimen is treatment courses up to six weeks in duration. The authors stated that Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The authors suggest that an extended treatment course of one to two weeks may be appropriate for patients who experience only partial improvement and the clinician believes that a clear plateau of benefit has not been obtained. In this case, the patient started TMS therapy in early July 2017 and had already utilized this additional timeframe by 10/5/17. Further, on 8/24/17, the patients Patient Health Questionnaire (PHQ-9) score plateaued after treatment 22 at which time the patient was noted to be feeling better. On 9/18/17, the patients mood was much improved. She was doing better and rated her depression a 1 out of 10. At that time, the patients diagnosis was major depressive disorder, in full remission. Given the lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy, the request for additional TMS services have not been established as medically necessary for treatment of the patients medical condition. Therefore, the requested services 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 1


A 28-year-old female enrollee has requested reimbursement for the Anser ADA testing performed on 12/1/15. The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees medical condition.  The physician reviewer found that the Anser ADA testing performed on 12/1/15 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based on the documentation submitted for review, there is a lack of clinical indication for the testing at issue. The patient was not experiencing failure of the anti-tumor necrosis factor agent as the patient was reported to be doing well with Humira. Given the above, the testing at issue 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 3


A 21-year-old female has requested reimbursement for Anser IFX testing performed on 8/17/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees ulcerative colitis. The physician reviewer found the management of ulcerative colitis using Anser IFX testing has not been standardized, and standardized recommendations for management based on test results (change to a different medication versus increase in dose) have not been formed. The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  Per the clinical literature, Anser IFX testing performed on 8/17/15 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: Experimental
Decision: Upheld

Summary Reviewer 3
A 54-year-old male enrollee has requested reimbursement for DecisionDx melanoma test performed on 11/9/16. The Health Insurer has denied this request indicating that the service at issue was considered investigational for evaluation of the enrollee who presented with a mole on his left upper back.   The physician reviewer found that cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. The data on the DecisionDx test for melanoma has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. This was also the consensus opinion of the National Comprehensive Cancer Network (NCCN) guidelines. In sum, DecisionDx melanoma gene expression test performed on 11/9/16 was not likely to have been more beneficial than the standard treatment options for evaluating this patients medical condition. Therefore, for the reasons stated above, the service at issue was 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: Overturned

Summary Reviewer 1

A 58-year-old female enrollee has requested reimbursement for the breast tomosynthesis provided on 12/28/15.  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 the breast tomosynthesis performed on 12/28/15 was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) has urged the tomosynthesis be removed from the investigational category due to the advantages this tomographic technique provides radiologists interpreting mammograms. This technique often allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. For this reason the addition of tomosynthesis to the usual two-dimensional (2D) protocol was likely of more benefit for the patient than had her mammogram been done using 2D technique only. 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 3


The parent of a 16-year-old female enrollee has requested authorization and coverage for ceftriaxone sodium injection. The Health Insurer has denied this request indicating that the requested medication is at investigational for the treatment of the enrollees Lyme disease. The physician reviewer found the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a diagnosis of chronic Lyme disease and is requesting an extended intravenous therapy with ceftriaxone. However, per the documentation submitted for review, the patients symptoms are not consistent with Lyme disease and there are no abnormal physical exam findings. In addition, the there was no Western blot submitted or Centers for Disease Control and Prevention criteria based immune assay for Borrelia burgdorferi. Moreover, the studies in the peer-reviewed literature have not supported the use of long term or extended therapy for the treatment of Lyme disease beyond four weeks. Thus, infusion medication with ceftriaxone is not likely to be more beneficial treatment than standard medical therapy in this clinical setting. Based upon the information set forth above, the requested medication 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

The patient is a 62-year-old male who has been diagnosed with melanoma of at least 1.0 mm Breslow depth on the left parietal scalp. The provider sent a sample tissue for testing to assess metastatic risk. The patient has requested reimbursement for the DecisionDx-Melanoma test (84999) performed on 1/12/17. The Health Insurer denied reimbursement and reported that the services at issue were considered investigational for the evaluation of this patients medical condition. The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting as it is considered to be investigational. The use of this type of testing is not considered to be standard of care in this clinical setting. Thus, its use is not expected to affect the treatment of this patients melanoma. As such, the results from DecisionDx-Melanoma test (84999) performed on 1/12/17 was not likely to have been superior over the other standard treatment options for the evaluation of this patient.  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: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 60-year-old male enrollee has requested authorization and coverage for Korlym 300 mg tablet. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees recurrent meningioma.  The physician reviewer found that on the presented clinical records submitted for review, Korlym 300 mg tablet is medically necessary for treatment of the patients medical condition. Meningiomas are brain tumors arising from the dura mater of the brain. Radiation therapy after complete surgical resection is the standard of care for atypical meningiomas. Systemic therapy is indicated for patients in whom surgical resection is not possible and those with high grade disease. The medical evidence to support various chemotherapy agents comprises of observational studies (Newton). Since the disease is uncommon, there is a lack of rigorously designed randomized clinical trials confirming the use of chemotherapy. In this case, the patient has received the standard of care and the tumor has progressed. Radiation has been exhausted as a therapy systemic therapy must be tried. Small phase II trials have confirmed responses to Korlym treatment as well (Grunberg, et al; Touat, et al). Treatment with Korlym is more targeted since many meningiomas express progesterone receptors. Therefore, the use of Korlym 300 mg is appropriate and medically necessary and supported by the current medical literature for treatment of this patients recurrent meningioma. 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

A 54-year-old male enrollee has requested authorization and coverage for neurostimulator electrode array and pulse generator. The Health Insurer has denied this request and reported that the requested services are investigational for the treatment of the enrollees medical condition. The physician reviewer found that hypoglossal nerve stimulation has been approved by the U.S. Food and Drug Administration for the treatment of moderate to severe obstructive sleep apnea refractory to continuous positive airway pressure. However, research comparing its effectiveness to existing alternatives is lacking. Schwartz and colleagues conducted a systematic review comparing continuous positive airway pressure with mandibular advancement devices in adult patients with mild to severe obstructive sleep apnea. The authors determined that although continuous positive airway pressure improved the apnea-hypopnea index significantly more than mandibular advancement devices, continuous positive airway pressure users also were significantly less compliant with their devices compared to mandibular advancement device users. This discrepancy in usage likely contributed to results showing similar levels of improvement in the interventions across quality of life, cognitive, and functional outcomes. Overall, there is insufficient peer-reviewed evidence to support the use of hypoglossal nerve stimulation over other available therapies. Therefore, CPT codes 64568 and 0466T are not likely to be more beneficial than other treatment options.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer  
The patient is a 55-year-old male who presented with symptoms compatible with obstructive 
sleep apnea (OSA). The patient has requested reimbursement for an oral device/appliance 
provided on 11/12/20. The physician reviewer found that American Academy of Sleep Medicine 
(AASM) guidelines state that oral appliance therapy is an option to treat obstructive sleep apnea 
when  CPAP  therapy  is  declined  or  cannot  be  tolerated.  The  AASM  guidelines  state,  We 
recommend  that  sleep physicians  consider prescription  of oral  appliances,  rather than  no 
treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or 
prefer alternate therapy. Therefore, the oral device/appliance provided on 11/12/20 was 
medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a nine-year-old transgender male enrollee has requested authorization and coverage for Supprelin LA KIT 50 mg. The Health Insurer has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees gender dysphoria. The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. It is well established that patients who have gender dysphoria often suffer from psychiatric comorbidities that worsen during puberty, at which time they are at high risk of suicide. Psychiatric comorbidity such as depression, anxiety, and suicidality is common in transgender youth, two to three times more frequent than among cisgender controls. The studies indicate that there is an ideal window of opportunity for patients to receive hormonal intervention, necessitating prompt referrals, which is around sexual maturity rating 2, and not later. Several studies confirm that many of the adverse psychological outcomes noted in transgender youth may be preventable with early recognition, hormonal treatment, and mental health support. There is now strong evidence, for subjects receiving pubertal suppression followed by hormone replacement therapy during adolescence, and gender reassignment surgery in adulthood, that all have improved psychological outcomes and quality of lives compared with those not receiving this therapy. Accordingly, the studies support a benefit with initiation of pubertal blockers in this patients case.  As such, Supprelin LA KIT 50 mg is likely to be of greater benefit for treatment of this patients medical condition than the available standard methods. Based upon the information set forth above, the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.