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

Summary Reviewer 1

A 61-year-old male enrollee has requested reimbursement for gene expression profiling performed on 5/10/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that patients with superficial bladder cancer are followed with serial cystoscopies and urine cytology. There are a variety of molecular-based markers being studied to improve the results of cytology alone. CxBladder testing has a 93% sensitivity and an 80 to 85% specificity, both of which are better than cytology alone. It is particularly being used in patients whose bladder tumors are deemed to be high risk for recurrence. There is sufficient support for the services at issue in this clinical setting. Therefore, gene expression profiling performed on 5/10/19 was likely to have been more beneficial than other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 


A 47-year-old male enrollee has requested authorization and coverage for Harvoni.  The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition. The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient.  Therefore, the requested medication is medically necessary for treatment of the patients medical condition. The Health Insurers denial should be overturned.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a 15-year-old male enrollee has requested reimbursement for the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15.  The Health Insurer has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees Crohns disease.  The physician reviewer found the unlisted chemistry procedure, Anser IFX assay testing (CPT code 84999) performed on 11/17/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The testing at issue is standard for patients treated with infliximab. The information received from Anser IFX assay testing may lead to a shortened interval or increased dose or possibly change of medication. In addition, Anser IFX assay testing indicates whether serum levels of the drug are in the range to be beneficial and effective or if the patient has antibodies that could potentially lead to a reaction or failure to respond. Anser IFX assay testing results can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication. This can also prevent the patient from having a flare and prevent potential side effects. All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Based upon the information set forth above, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 50-year-old male enrollee has requested reimbursement for MRI of the pelvis without and without dye performed on 7/24/18. 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 clinical model for the approach to diagnosing prostate cancer is quickly moving towards the use of MRI targeted biopsy. The medical evidence indicates the superiority of this modality compared to traditional biopsy, resulting in a decrease in the number of false negative results, improved tumor characterization and localization, as well as better treatment planning. According to the American College of Radiology appropriateness criteria in the setting of clinically suspected prostate cancer in a patient without history of prior biopsy, MRI with subsequent targeted biopsy is considered usually appropriate. In this case, the patient had clinically suspected prostate cancer given his elevated PSA and strong family history. Therefore, MRI prior to prostate biopsy was indicated. Therefore, MRI of the pelvis with and without dye performed on 7/24/18 was medically necessary for the evaluation of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 23-year-old male enrollee requested authorization and coverage for E1399 (functional electrical stimulation cycle ergometer). The Health Insurer has denied this request and reported that the requested device is investigational for the treatment of the enrollees medical condition. The physician reviewer found that this patient has a history of a spinal cord injury at the C7 level. The records document associated spasms in the lower extremities and elbow pain. The patients provider has recommended use of a functional electrical stimulation (FES) cycle ergometer for this patients physical rehabilitation following spinal cord injury. Kressler and colleagues assessed the use of home-based functional electrical stimulation cycle ergometers. The authors noted the key findings of this study are that usage frequency of home-based FES cycling is below recommended levels for weekly use and caloric expenditure is below the recommended levels for the majority of persons with spinal cord injuryOverall, we find that users of home-based FES cycling are below authoritative standards for overall health maintenance. Ralston and colleagues noted there were no clear effects of FES cycling on urine output, swelling and spasticity even though all point estimates of treatment effects favored FES cycling and participants perceived therapeutic effects. There is a lack of clinical research demonstrating significant benefit of FES units as an adjunct treatment for spinal cord injury. In sum, E1399 (functional electrical stimulation cycle ergometer) is not likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


A 28-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 and shortness of breath. The physician reviewer found that this patient meets the established criteria for bronchial thermoplasty based on age, pulmonary function, severity of condition and treatment program. Her computed tomography (CT) scan showed diffuse mild bronchial wall thickening but no bronchiectasis which would contraindicate bronchial thermoplasty. Bronchial thermoplasty is a newer treatment for severe asthma, now included in GINA (Global Initiative for Asthma) guidelines. The American College of Chest Physicians also considers bronchial thermoplasty an important treatment option for adult patients with severe asthma who continue to be symptomatic despite maximal medical treatment. Wechsler and colleagues showed bronchial thermoplasty is an effective and safe therapy with reductions in exacerbations lasting to at least five years. While some studies have shown short-term increase in asthma morbidity, long lasting improvement appears to be the most common outcome. Consistent with this support, the requested bronchial thermoplasty is likely to provide this patient with greater benefits than any available standard therapy. Based upon the information set forth above, the requested procedure 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.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 23-year-old female enrollee has requested reimbursement for Prometheus Anser IFX testing performed on 4/29/15. 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 there is some support for the services at issue in this clinical setting.  Singh and colleagues discussed therapeutic drug monitoring (TDM) in children and young adults with inflammatory bowel disease (IBD).  According to the paper by Singh and colleagues, The clinical value of TDM [therapeutic drug monitoring] is increasingly being recognized, with the growing body of evidence linking serum anti-TNF drug and ADA concentrations to clinical outcomes in IBD. The knowledge of these results provides insight into the etiology of loss of response and enables therapy to be optimized for an individual patient.  Per the submitted documentation, Prometheus IFX testing performed on 4/29/15 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: Upheld

Summary Reviewer 

The patient is a 59-year-old female who self-palpated a right breast mass in January 2020.  The patient has requested authorization and coverage for proton beam therapy. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that guidelines do not endorse the routine use of proton therapy in the treatment of breast cancer. There is a lack of data to suggest that proton therapy would be beneficial in this case or that it would be associated with less side effects than standard treatment with photons. The standard treatment in this case would be with chemotherapy followed by surgery followed by radiation with photons. Furthermore, consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation or 3D conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Also, there is a lack of level I evidence to support the use of proton beam therapy for the treatment of breast cancer. Therefore, proton beam therapy is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 42-year-old female enrollee has requested authorization and coverage for total disc replacement. 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 this patient has a history of anterior cervical discectomy and fusion at C6-7 and adjacent level degenerative disc disease with radiculopathy at C5-6 and C4-5. She has tried and failed conservative treatment, and her provider has requested total disc replacement at these levels. Hybrid surgery in the cervical spine may lead to better neck disability index recovery, less postoperative neck pain, faster cervical range of motion recovery, and less adjacent segment disease. There is support for the requested services in this clinical setting. Thus, the requested total disc replacement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


A 68-year-old female enrollee has requested authorization and coverage for iStent placement (times two).  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 current medical evidence supports the requested iStent placement (times two) in this clinical setting.  The peer-reviewed has demonstrated the superior efficacy of the requested services in this patients case.  Studies reviewed indicate that this procedure is a safe and effective modality for achieving better glaucoma control after cataract surgery.  Thus, iStent placement (times two) is likely to be more effective than other treatment alternatives.  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: Upheld

Summary Reviewer 2


A 46-year-old male enrollee has requested reimbursement for the gastrointestinal (GI) effects comprehensive profile stool testing performed on 1/10/16. 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 based on the documentation submitted for review, the GI effects comprehensive profile stool testing was not likely to be more beneficial for evaluation of the patients medical condition than standard testing. Specifically, the polymerase chain reaction (PCR) assessment of enteric pathogens and the ova and parasite components of the comprehensive profile stool testing were duplicative to studies the patient reports were already performed. In addition, the calprotectin assay was not indicated since colitis had already been ruled out by previous colonoscopy and computed tomography (CT) imaging. As such, the GI effects comprehensive profile stool testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 56-year-old female enrollee has requested reimbursement for the hip surgery (CPT codes 29914 and 29915) provided on 6/17/16. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees right hip impingement syndrome. The physician reviewer found that in the peer-reviewed medical literature, Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. The authors reported that when nonsurgical treatment methods fail, surgical options were recommended, but there was no long-term outcome data to support one method over another. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. This patient presented with a three year history of hip pain that had severely worsened six months prior to initial examination. The pain interfered with her work duties and activities of daily living. Clinical examination findings were consistent with femoroacetabular impingement syndrome. She failed over six months of conservative treatment including activity modification, chiropractic care, ice, and anti-inflammatory medications. There were no significant degenerative findings of the right hip. Therefore, the right hip arthroscopy with femoroplasty and acetabuloplasty (CPT codes 29914 and 29915) performed on 6/17/16 was 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 

A 41-year-old male enrollee has requested authorization and coverage for rituximab injections 100 mg. The Health Insurer has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees pretibial myxedema. The physician reviewer found that the use of rituximab for ocular related findings associated with Graves disease is supported by peer-reviewed medical literature. However, there is a paucity of large, controlled studies demonstrating the safety and efficacy of rituximab for treatment of pretibial myxedema (Heyes, et al; Ferreira-Hermosillo, et al). As this patient does not have any documented ocular related findings associated with Graves disease, the requested rituximab injections 100 mg are not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, 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 2 
 
A 46-year-old male enrollee has requested authorization and coverage for Acthar Gel. The Health 
Insurer has denied this request indicating that the requested medication is investigational for the 
treatment of the enrollees sarcoidosis. The physician reviewer found that Gerke explains that 
treatment  of  sarcoidosis  involves  the  use  of  corticosteroids  and  conventional 
immunosuppression with medications such as methotrexate, azathioprine, leflunomide, and 
mycophenolate. Baughman and colleagues note, The biologic agents, especially monoclonal 
anti-tumor necrosis factor (anti-TNF) antibodies, have proved effective in patients who have 
failed other treatments. While Acthar Gel is FDA-approved for the treatment of symptomatic 
sarcoidosis, in this clinical setting, current medical literature does not support its use as superior 
to multiple other treatment options that have been proven to be effective for the treatment of 
sarcoidosis. Therefore, Acthar Gel is not likely to be more beneficial for treatment of the patients 
condition than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 2

A 44-year-old female enrollee has requested authorization and coverage for sacroiliac joint fusion. The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees sacroiliac joint pain. The physician reviewer found that the sacroiliac joint degeneration is a common cause of chronic low back pain which is underdiagnosed. Minimally invasive fusion procedures have demonstrated successful pain relief for these patients.  Recent medical literature has documented two-year follow-up of these procedures demonstrating meaningful clinical improvement and maintained pain relief as well as evidence of a solid fusion on imaging studies. In the absence of evidence of neural compression on the magnetic resonance imaging (MRI) scan and in the presence of clinical findings of sacroiliac pain which is relieved by injecting the sacroiliac joint, the requested procedure of sacroiliac fusion using the minimally invasive technique is likely to be beneficial in this case. As such, the requested sacroiliac joint fusion is likely to be of greater benefit than other treatment options. 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: Upheld

Summary Reviewer 2


A 62-year-old male enrollee has requested reimbursement for the RT300 functional electrical stimulator (FES) cycle provided on 2/10/16. The Health Insurer has denied this request indicating that the equipment at issue was considered investigational for treatment of the enrollees quadriplegia.   The physician reviewer found that currently, there is a paucity of proven significant health or functional benefits of exogenous neurostimulation therapy of paralyzed muscles using FES cycle ergometry for use in this clinical setting. There have been a number of case reports and series providing some preliminary data suggesting possible benefits, but larger studies designed to evaluate the actual clinical efficacy of passive exercise such as FES cycle ergometry in the setting of spinal cord injury are lacking. While repeated bouts of exogenous neurostimulation of paralyzed muscle may potentially retard or reverse muscle atrophy in paralyzed muscle, there is no proven significant health or functional benefit of this achievement in patients with spinal cord injury because the muscle tissue that is gained or spared does not protect against pressure ulcers or provide any other clinically or functionally relevant benefit. Passive cycling may be an option to provide passive range of motion therapy to prevent contractures or mitigate spasticity, but this is considered a custodial use of the device (Reichenfelser, et al). The other purported benefits of passive cycling have not been sufficiently investigated to allow conclusions related to clinically relevant outcomes. To date, the limited available data provide mixed results regarding health measures. Given that the RT300 FES cycle is not active exercise and not an appropriate substitute for active exercise, its use in this patients care was not indicated. Thus, the RT300 FES cycle provided on 2/10/16 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 equipment 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: Experimental
Decision: Upheld

Summary Reviewer 2

A 30-year-old female enrollee has requested reimbursement for Prometheus Anser ADA (84999) provided on 10/14/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees inflammatory bowel disease (IBD). The physician reviewer found that monitoring patients on adalimumab with measurement of adalimumab levels and antibodies to adalimumab continues to be an area of interest in the inflammatory bowel disease community. In general, adalimumab levels correlate inversely with disease activity. However, there is a lack controlled data which has identified the optimal drug level and so, the issue remains speculative. This patients level was in the normal range despite the fact that he was having an active flare/progression of disease, highlighting the limitation of the test. Using the Anser ADA, one can set up a hypothetical table categorizing drug levels as high or low and antibody levels as high or low. In theory, one could use this table to determine whether to dose increase or switch to a biologic agent with a different mechanism of action. However, this hypothetical benefit is not supported by high quality medical evidence. In sum, Prometheus Anser ADA (84999) provided on 10/14/15 was not likely to have been more effective than other modalities in 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.