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

Summary Reviewer 1

A 33-year-old female enrollee has requested reimbursement for fecal lactoferrin testing performed on 12/06/19. 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 in MosliAaas comparative meta-analysis of 19 studies, the diagnostic accuracy of C-reactive protein, fecal calprotectin, or stool lactoferrin was examined against endoscopy as a gold standard in
patients with symptoms/signs consistent with active inflammatory bowel disease. Fecal calprotectin was found to be more sensitive than C-reactive protein for this patientAaas indication. Similar results were reported by Menees and colleagues. In this meta-analysis which evaluated the performance of fecal calprotectin in distinguishing between inflammatory bowel disease and irritable bowel syndrome, patients with a fecal calprotectin level of less than 40 microg/g had a 1 percent chance or less of having inflammatory bowel disease. Fecal calprotectin has in recent years become increasingly attractive to some clinicians for assessment of inflammatory bowel disease activity in lieu of direct imaging of the gut.
Whereas conditions like irritable bowel syndrome and CrohnAaas disease could have been suspected as contributory to the patientAaas symptoms, no specific mention was made by the patientAaas provider that inflammatory bowel disease was under consideration. In this case, lactoferrin testing was not supported in the face of many other concomitantly-ordered inflammatory markers that proved negative, such as C-reactive protein, sedimentation rate, leukocyte count, or fecal calprotectin. With so many other negative inflammatory markers, the likelihood of a missed inflammatory bowel disease diagnosis was remote. Therefore, fecal lactoferrin testing performed on 12/06/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

A 53-year-old female enrollee has requested authorization and coverage for autologous cultured chondrocytes implant knee. 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 presents with a history of progressively worsening bilateral knee pain. Functional difficulty is reported in activities of daily living and recreational pursuits. She is status post bilateral knee arthroscopy, chondroplasty, synovectomy, and plica resection, and chondral biopsy on the right knee on 7/18/18. The surgeon reports left knee operative findings included a grade IV chondral defect in the lateral facet of the patella measuring 2 x 2 cm, and a grade III defect on the anterolateral trochlea measuring 5 x 5 mm. All defects had been debrided back to stable margins with Outerbridge grade I/II at the lesion borders. She subsequently underwent right knee surgery, including the matrix-induced autologous chondrocyte implantation procedure. Evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. Under consideration is a request for left knee matrix-induced autologous chondrocyte implantation. There is U.S. Food and Drug Administration (FDA) approval for the use of matrix-induced autologous chondrocyte implantation in this clinical setting. There is current peer-reviewed evidence indicating that matrix associated chondrocyte implantation is safe and effective for the treatment of full thickness cartilage defects in the knee, with no effect of the location of the defects or number of defects on study outcomes. In sum, autologous cultured chondrocyte implantation in the knee is likely to be more beneficial than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested reimbursement for the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees superficial vein thrombophlebitis. The physician reviewer found that patients who have had a deep venous thrombosis have a high prevalence of inherited thrombophilic disorders (Merriman and Greaves). However, the current medical literature does not support routine Factor V Leiden genetic testing and homocysteine testing for patients based on the presence of superficial venous thrombosis (Nakashima and Rogers). All told, the Factor V Leiden genetic testing and homocysteine testing provided on 3/23/16 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 62-year-old female enrollee has requested reimbursement for Guardant360 testing performed on 7/25/20.  The Health Insurer indicates that the services at issue were investigational for the evaluation of the enrollees medical condition. Therefore, the Health Insurer has denied reimbursement for the services at issue. The physician reviewer found that adenocarcinoma of the lung should be evaluated for specific molecular and mutational targets, such as EGFR. ALK, ROS-1, and PDL-1 positivity. Each of these has a therapeutic implication. Usually, these are analyzed from the tissue biopsy specimen, although plasma assay does appear to be a reasonable substitute when tissue biopsy is not possible or safe. Even beyond that issue, in lung cancer, there is some data to indicate that plasma assay may actually be superior to tissue. Agarwal studied this issue in 323 patients, many of whom had both types of assays, but many only had the serum assay. It was noted that 33% of those who had only the serum assay had a targetable mutation, and 86% of these experienced a clinical response to treatment. Only 21% of those who had tissue assay alone had such a targetable situation. There is sufficient support for the services at issue in this clinical setting. Therefore, Guardant360 testing performed on 7/25/20 was likely to have been more beneficial than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 53-year-old male with a history of clinically localized favorable intermediate risk adenocarcinoma of his prostate gland. The patient has requested reimbursement for 17 fraction treatments of IMRT provided from 3/05/21 through 3/29/21. The Health Insurer has denied this request and reported that the services at issue were 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 services at issue. The 17 additional fractions of IMRT were standard of care and medically necessary in this clinical setting. While hypofractionation is proven equivalent in terms of safety/efficacy for treatment of prostate cancer, conventional fractionation (45 fractions as requested) is standard of care and continues to be widely utilized throughout the radiation oncology community. National Comprehensive Cancer Network guidelines support the use of 45 fractions of IMRT in this setting, as do numerous high-quality prospective clinical outcomes published in the peer-reviewed medical literature. Therefore, 17 fraction treatments of IMRT provided from 3/05/21 through 3/29/21 were medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3


A 41-year-old male has requested authorization and coverage for the LINX procedure.  The Health Insurer has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. The physician reviewer found there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures.  At this time, additional studies are needed to determine the long-term safety and efficacy as compared to other treatment modalities.  Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention, which is a concern in this patients case.  The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication.  Thus, the requested LINX procedure is not likely to be more effective than other treatment options.  Based upon the information set forth above, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer  
The patient is a three-year-old male. An assessment dated 3/2/22 reported that the patient did not 
have a history of seizures. The patients parent has requested reimbursement and prospective 
authorization and coverage for private duty nursing, 12-hour days, seven days per week, from 
3/1/22 to 12/31/22. The Health Insurer has denied this request and reported that the services at 
issue were not and 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  the  submitted 
documentation does not support the medical necessity of the services at issue. Home based nursing 
services are essential for parents of children with life-limiting diseases with basic healthcare needs 
including  personal  hygiene  and  feeding,  the  administration  of  drugs  and  management  of 
symptoms, and pain and sleep related problems during the night. Lazzarin and colleagues report 
that  parents providing palliative care for children with life-limiting diseases spent an average of 
nine hours a day caring for them each day and had to maintain an average of five medical 
appliances. It is important for these families to receive appropriate support with daily care through 
an evaluation of the childs individual needs. Current medical literature shows that the number of 
medical appliances and the status of single caregivers correlate proportionally with a greater 
amount of time needed for a childs care. The data suggests that it is not so much the childs disease 
that determines the daily burden of care for the parents, but the number of different procedures 
that must be expertly managed. In this case, the patient is not dependent on a ventilator, is not 
using a feeding pump or indwelling catheters, and does not have life threatening seizures. Unlike 
children with incurable conditions who are cared for at home and need highly complex medical 
care, this childs quality-of-life may be adequately maintained without 12 hours/day in home 
nursing service. Given that this patient does not have multiple chronic conditions or life-limiting 
diseases that make him dependent on caregivers and the use of complex medical appliances or of 
life sustaining medical devices, the services at issue were not and are not medically indicated. 
Therefore, private duty nursing, 12-hour days, seven days per week, from 3/1/22 to 12/31/22, was 
not and is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1


A 64-year-old female enrollee has requested reimbursement for Botox injections received on 10/9/14 and 10/29/15.  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 the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with a history of bilateral breast cancer (at different times) and immediate breast reconstruction at two different time periods. Due to elevation of the pectoralis muscle, she underwent Botox administration for chemodenervation as a way to decrease muscle spasm and decrease postoperative pain. Although there may be some anecdotal evidence for the use of Botox when elevating the pectoralis muscle in breast reconstruction and augmentation mammoplasty to decrease muscle spasm and postoperative pain, there is insufficient evidence that Botox would be likely more beneficial than standard treatment in breast reconstruction. Therefore, without greater study with respect to Botox use in standard breast reconstruction, its use in this clinical setting was not likely to be more beneficial for treatment of the patients medical condition than other modalities. 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: Medical Necessity
Decision: Overturned

Summary Reviewer 

The patient is a 62-year-old female with a history of mild bilateral carotid artery atherosclerosis, hyperlipidemia and hypertension.The patient has requested authorization and coverage for Repatha. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of this patient. The physician reviewer found that the patient has prior evidence of established atherosclerotic vascular disease of the carotid arteries. She has hypertension and hyperlipidemia with a baseline LDL of 166. She is at risk for progression of her peripheral vascular disease and also development of coronary artery disease based on her age and risk factors. She was intolerant of four different statin medications and ezetimibe, which all had to be discontinued. She has had an excellent response to PCSK-9 therapy with Repatha, which has decreased her LDL to her goal without further side effects. Based on her known carotid artery disease, additional risk factors for coronary artery disease and intolerance of multiple statin therapies, PCSK-9 inhibitor therapy with Repatha is medically indicated. Therefore, Repatha is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 47-year-old male enrollee has requested authorization and coverage for hypoglossal nerve stimulation or Inspire upper airway stimulation system. 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 there is sufficient support for the requested services in this clinical setting. The records noted intolerance to the use of continuous positive airway pressure therapy. A sleep study documented symptoms of obstructive sleep apnea with an apnea-hypopnea index at the moderate to severe level of obstructive sleep apnea syndrome, with oxygen desaturation to 82%. Hypoglossal nerve stimulation therapy has been demonstrated to be an effective modality for the treatment of obstructive sleep apnea in patients with tongue-based obstruction. The medical evidence supports the requested services for the treatment of this patient. Thus, the requested hypoglossal nerve stimulation or Inspire upper airway stimulation system is likely to be of greater benefit than other treatment options.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2

The parent of a five-year-old male enrollee has requested reimbursement for gene testing performed on 11/20/15. The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees generalized epilepsy of unknown etiology. The physician reviewer found the gene testing performed on 11/20/15 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. CMA has become standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or congenital anomalies. Seven percent of microarray results impact clinical management, a rate which is similar to other genetic tests (Riggs, et al). Olson and colleagues found that at least 5% of individuals with epilepsy had pathogenic copy number variants. In sum, data have emerged showing that actionable findings from chromosomal microarray justify its use. 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 59-year-old female enrollee has requested authorization and coverage for lumbar spine decompression and fusion. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that this patient presents with worsening low back pain radiating down the right lower extremity in an L4 distribution with associated numbness and tingling. Significant functional limitations are noted in activities of daily living and mobility. Her signs and symptoms are reported as positional and consistent with neurogenic claudication. She has failed to achieve adequate relief with long-term conservative treatment. Clinical examination findings have evidenced reflex changes consistent with imaging evidence of nerve root compromise and prominent facet degenerative change with facet cysts at the L4-5 and L5-S1 levels. There is reported radiographic evidence of spondylolisthesis at L4-5 and L5-S1 with spinal instability reported of 6-10 mm. Additionally, there is plausible need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. The medical literature supports lumbar decompression and fusion in this clinical setting. Therefore, the requested lumbar spine decompression and fusion is medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 23-year-old male enrollee has requested reimbursement for mental health residential treatment provided from 5/10/15 through 8/05/15.  The Health Insurer has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health conditions.  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not a danger to himself or others.  The records do not document that he was aggressive, agitated, hostile, manic, or psychotic.  There was no physician evaluation on admission, psychiatric or otherwise.  There were no skilled nursing services provided.  Groups were on a weekly, not daily, basis, and records do not show that therapeutic services were provided on a multiple-hours per day basis.  The current medical evidence does not support the services at issue in this patients case, as there is no record of his behavior being hostile, aggressive, risky, dangerous to himself or others, or out of control prior to admission.  The patient could have been treated on an outpatient basis, which would have been seen as the standard of practice in the community.  All told, mental health residential treatment provided from 5/10/15 through 8/05/15 were not medically indicated for the treatment of this patient.  Therefore, the services at issue were not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 26-year-old female enrollee has requested reimbursement for DecisionDx testing performed on 4/28/17. The Health Insurer has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees cutaneous melanoma. The physician reviewer found that the DecisionDx-Melanoma test is an attempt to determine risk of recurrence for early stage melanoma. However, the treatment protocol for follow up of melanoma patients is summarized in the National Comprehensive Cancer Network (NCCN) guidelines. These guidelines note there is a lack of data to support using adjuvant therapy based on DecisionDx testing results. The follow up of melanoma patients is not tailored to each patient risk of recurrence, but rather is global to all patients with melanoma. Given these findings, the DecisionDx testing performed on 4/28/17 was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Based upon the information set forth above, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

The patient is a 55-year-old female with rheumatoid arthritis who has failed multiple therapies. These therapies have included Actemra, Simponi, Orencia, Humira and recently Xeljanz. The patient did not tolerate Arava. On 8/18/16, the records noted that the patient had been on Remicade in the past, and this medication was both tolerated and effective. The provider ordered Prometheus Anser IFX testing to determine if antibodies had been formed against infliximab (Remicade) due to prior therapy with Remicade and to determine if this would be a suitable next therapy. The Health Insurer has denied reimbursement for Prometheus Anser IFX testing performed on 8/19/16.  Per the Health Insurer, the services at issue were investigational for the evaluation of this patient.  There is a lack of support for Prometheus Anser IFX testing in this patients case.  The services at issue are not standard of care prior to starting patients on Remicade, even if they have been on it before.  There is a lack of literature to support that testing of these antibodies changes the overall outcome or prognosis. Additionally, antibodies to anti-tumor necrosis factor agents can occur any time during therapy, but most often occur at the beginning of therapy and may be transient. Patients with anti-tumor necrosis factor antibodies do not necessarily always demonstrate a lack of response to therapy. Therefore, there is no one-to-one correlation between antibody formation and presence and failure to respond to Remicade.  Thus, Prometheus Anser IFX testing performed on 8/19/16 was not likely to be more effective 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.