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

Summary Reviewer 3

A 49-year-old male enrollee has requested reimbursement for a positron emission tomography (PET) scan performed on 6/30/17. 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 that with the limited information that was provided, it seems that patient was found to have retroperitoneal lymphadenopathy, for which he underwent CT-guided bone marrow biopsy and then PET scan. Assuming that the cause of lymphadenopathy is unknown, CT-guided tissue sampling for bone marrow would be a standard approach. Also, to find out the extent of lymphadenopathy in the remaining body parts such as neck, chest, abdomen and pelvis, PET was also indicated. Thus, PET scan performed on 6/30/17 was 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overturned.
Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 
The patient is a 24-year-old female with a medical history significant for congenital central hypoventilation syndrome and subsequent cardiac arrhythmia, requiring pacemaker placement. The patient has requested authorization and coverage for a home ventilator. The Health Insurer has denied this request and reported that the requested equipment is not medically necessary for the treatment of this patient. The physician reviewer found that congenital central hypoventilation syndrome is an extremely rare disorder. These patients lack the expected arousal response to hypoxemia and hypercarbia during sleep, and in extreme cases, during wakefulness as well. They do not respond like typical patients to exercise or infection, either because they do not perceive hypoxemia or hypercarbia. They are at long-term risk for cardiac abnormalities and pulmonary hypertension. Management of these patients involves and requires ventilatory support with non-invasive or tracheostomy-associated mechanical ventilation. This is the standard of care and it is life-preserving and lifesaving in this very complicated yet small patient population. Therefore, the requested home ventilator is medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 1

A 35-year-old female has requested reimbursement for Oncotype Dx Colon Cancer Assay provided on 11/16/18. The Health Insurer has denied this request indicating that the services at issue were investigational for the evaluation of the enrollees medical condition. The physician reviewer found that Adjuvant chemotherapy is of benefit to patients with stage III (node positive) colon cancer. It is much more controversial as to the usefulness of adjuvant chemotherapy in stage II colon cancer, as in this patients case. Most oncologists make this decision based on specific pathologic and clinical features in an individual that imply higher risk of recurrence. Among these features that can place a patient in a higher risk category are poorly differentiated histology, a pT4 lesion, lymphovascular invasion, or presentation with perforation/obstruction. In this case, the records do not document these features. Oncotype DX Colon Cancer Assay is a 12-gene panel that may predict the risk of recurrence in both stage III and II colon cancer. However, it is not clear if the assay can be used to predict the value of adjuvant chemotherapy in the absence of other high risk features. Therefore, Oncotype DX Colon Cancer Assay performed on 11/16/18 was not likely to have been of greater benefit than other methods of evaluating this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 1

A 57-year-old female enrollee has requested reimbursement for testing for cancer risk using panels of genes (MyRisk) provided on 6/05/19. 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 the submitted documentation supports the superior efficacy of a portion of the services at issue. Given that the patients mother developed breast cancer at age 36, she does fall within guidelines for BRCA testing. However, this patient was evaluated with the MyRisk panel, which is a 25 gene panel including BRCA. Although there is great interest in the other genes, there is little data to support making clinical decisions on the basis of the other genes alone. Even in families with a strong history, such as this one, it is not clear that the other genes significantly add to the risk profile beyond what the family history alone provides. Therefore, the BRCA portion of the testing was likely to have been more beneficial than other methods of evaluating this patient. However, the superior effectiveness of the remaining tests has not been established.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3

A 39-year-old male enrollee has requested authorization and coverage for Stelara (ustekinumab). The Health Insurer has denied this request indicating that the requested medication is investigational for treatment of the enrollees medical condition. The physician reviewer found that in this case, the patient presents with refractory Crohns disease manifest by severe ileitis. There is sufficient support in the peer-reviewed literature for Stelara to be utilized in this clinical setting. The study by Sandborn and colleagues found that patients with moderate to severe Crohns disease resistant to tumor necrosis factor (TNF) antagonists had an increased rate of response to induction with ustekinumab compared with placebo. In addition, the authors concluded that Patients with an initial response to ustekinumab had significantly increased rates of response and remission with ustekinumab as maintenance therapy. In light of lack of viable options to treat this patient with refractory, progressive Crohns disease and support in the peer-reviewed literature, Stelara medication is 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 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.
Appeal type: Medical Necessity
Decision: Upheld

Summary Reviewer 


A 26-year-old female enrollee has requested reimbursement for the L3-5 discectomy performed on 12/16/15. The Health Insurer has denied this request indicating that the surgery at issue was not medically necessary for treatment of the enrollees lumbar radiculopathy. The physician reviewer found the medical records, physical examination findings, and MRI findings do not support the medical necessity of the surgery at issue. There is no correlation between physical examination and imaging. In addition, there is no severe nerve root compression on MRI and the patient has not reportedly exhausted conservative measures. Moreover, there were no red flags for surgery or significant neurological deficit. All told, the L3-5 discectomy performed on 12/16/15 was not medically necessary for treatment of this patients medical condition. Based on the foregoing discussion, the surgery at issue was not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 3


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 testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Testing for the presence of antibodies to infliximab (ATI) is appropriate in the setting of an acute infusion reaction, even when not severe. These reactions are important immunological events which should prompt ATI and infliximab trough level determination (Lichtenstein, et al). The presence of ATI can help to determine likelihood of a future reaction. Patients who have ATI have more than a two-fold risk of a subsequent reaction, and nearly a six-fold risk of a severe reaction, compared to those who do not have ATI (OMeara, et al). In addition, allowing for assessment of future infusion reaction risk, the presence of ATIs may also help to guide therapeutic decision-making in regard to the potential addition of concomitant immunomodulatory therapy, which is known to decrease ATI level and decrease drug reaction risk (Ben-Horin, et al). Accordingly, 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. 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 2

The patient is a 63-year-old male with metastatic thymic cancer, stage IV with pleural dissemination. He was initially diagnosed in November 2014. On 4/29/15, he underwent an anterior mediastinal mass core biopsy and the results were suggestive of a thymic carcinoma. He underwent thymic mass resection and completed four cycles of chemotherapy. Other treatments included radiation and additional chemotherapy with cisplatin, epirubicin, and etoposide when he recurred. He had progression of the disease and his tumor was sent for FoundationOne testing to help guide treatment decision making. The patient has requested reimbursement for FoundationOne testing performed on 12/28/16. The Health Insurer denied this request and reported that the services at issue were investigational for the evaluation of this patients medical condition. Thymic carcinomas are rare epithelial malignancies with no clear therapeutic guidelines beyond first line therapy. Molecular profiling such as with FoundationOne testing offers molecular profiling that can differentiate thymic carcinomas from thymomas by identifying c-KIT mutations. The presence of a c-KIT mutation in thymic cancers has shown benefit to treatment with sunitinib or sorafenib. Molecular profiling can also help to differentiate thymic cancers from lung cancers as pathologically they are similar. As such, molecular profiling with FoundationOne testing performed on 12/28/16 was likely to have been more effective than any available standard therapy for evaluating the patients medical condition.  Therefore, for the reasons stated above, the services at issue were likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Insurers denial should be overtu
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 51-year-old female enrollee has requested reimbursement for hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15. The Health Insurer has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees breast cancer. The physician reviewer found that upon diagnosis with breast cancer, patients have two major surgical options, modified radical mastectomy or lumpectomy followed by radiation therapy.  From well-planned clinical trials with numerous patients, it is known that these two surgical approaches offer equivalent overall survival, but there are notable exceptions.  Breast conserving surgery does result in increased rates of locoregional recurrence, but this is diminished by the use of radiation therapy to the operative areas postoperatively.  However, there are absolute contraindications to lumpectomy. These contraindications include multicentric disease (two or more primaries in separate quadrants of the breast), diffuse microcalcifications, prior history of radiation therapy, pregnancy, and persistent positive margins. This is the case for this patient who had multifocal disease in the right breast. Local hyperthermia to ablate tumors or locoregional recurrence is considered standard care, but its use on a primary breast tumor before mastectomy is unusual. Thus, hyperthermia (77605 and 77600) provided from 11/03/15 through 12/15/15 was not likely to have been more efficacious than other available treatment 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: Upheld

Summary Reviewer 

A 45-year-old male enrollee has requested authorization and coverage for Otezla 10-20-30 milligram tablets, starter therapy pack. The Health Insurer has denied this request and reported that the requested medication is not medically necessary for the treatment of the enrollees medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient is requesting coverage for Otezla for the treatment of chronic plaque psoriasis. The records document that he has tried and failed therapy with Clobex spray and azithromycin. The Health Insurer has denied the request as not medically necessary as the patient has not tried and failed the formulary preferred agents. The submitted records do not indicate a treatment trial or contraindications to the use of methotrexate, cyclosporine, Humira, Enbrel, Cosentyx or Stelara. Thus, there are effective, alternative, formulary preferred agents available for use. Therefore, Otezla 10-20-30 milligram tablets, starter therapy pack is not medically necessary for the treatment of this patient.
Appeal type: Experimental
Decision: Overturned

Summary Reviewer 2


The parent of a three-year-old male enrollee has requested reimbursement for the FirstStepDx Plus testing performed on 12/14/15. The Health Plan has denied this request indicating that the testing at issue is considered investigational for evaluation of the enrollees autism spectrum disorder. The physician reviewer found that battaglia and colleagues performed a study to demonstrate the usefulness of CMA in detecting the etiology of unexplained autism spectrum disorders associated with dysmorphic features in a large cohort of pediatric patients. The authors concluded that their study confirmed the value of CMA as the first-tier tool in the assessment of those conditions in the pediatric setting. CMA has become the standard of care to evaluate children with developmental delay, intellectual disability, autism spectrum disorders or multiple congenital anomalies. The medical literature supports the testing at issue as an important and mainstream tool in the practice of clinical genetics. Given the support in the peer-reviewed literature, FirstStepDx Plus performed on 12/14/15 has been established as 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 55-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 hepatitis C virus. The physician reviewer found according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, AASLD/IDSA treatment guidelines recommend Harvoni for 12 weeks for treatment-naive patients with HCV genotype 1 infection. Therefore, based on national guidelines Harvoni is medically necessary in this clinical setting.For the reasons provided, 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 50-year-old female enrollee has requested reimbursement for the injection of periurethral bulking agent provided on 12/19/14. The Health Insurer has denied this request indicating that the service at issue was considered investigational for treatment of the enrollees recurrent stress urinary incontinence and intrinsic urethral sphincter deficiency.   The physician reviewer found that this patient presents with persistent stress urinary incontinence associated with urgency and urgency incontinence. She underwent multiple procedures which failed. Subsequently, the patient underwent urethral bulking agent injection therapy. The patient did undergo preoperative urodynamics. There was cystoscopy evidence that the patient had urethral hypermobility and the patient also had urgency. However, there was no evidence of an intrinsic sphincteric deficiency. At this time, the success rate for long-term urethral bulking agent therapy is significantly low and alternative surgical procedures would likely have provided this patient with a superior health outcome. Accordingly, the injection of periurethral bulking agent provided on 12/19/14 was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. Based upon the information set forth above, the service 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: Overturned

Summary Reviewer 3

The parent of a 13-year-old female enrollee has requested reimbursement for transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19. The Health Insurer has denied this request and reported that the services at issue were investigational for the treatment of the enrollees medical condition. The physician reviewer found that Nayback-Beebe and colleagues evaluating the efficacy of Scrambler Therapy on chronic pain. The authors found, The groups showed no statistically significant differences in pain scores, medication use, or mental or physical health-related quality of life with active versus sham treatment. However, both produced clinically meaningful reductions in pain and improvements in physical health-related quality post-treatment that was sustained at 1-month follow-up. The authors concluded, Scrambler Therapy is no better than sham treatment in decreasing pain. Yet, patient perceptions of treatment effectiveness are equally important in chronic pain treatment. Goh and colleagues performed a systematic review on current standards of care for complex regional pain syndrome. The authors described several of the current standard treatments, including physical therapy, psychological treatments, pharmacological therapies, as well as interventional treatments, including sympathetic blockade and surgical approaches. There is no mention of Scrambler Therapy as an accepted treatment for complex regional pain syndrome. 

In this case, the patient has complex regional pain syndrome that has not responded to physical therapy or epidural steroid injections. The current evidence supporting the Scrambler Therapy for chronic pain is very limited, with a lack of large randomized control studies to demonstrate clear benefit. Furthermore, there is a lack of studies in the published peer-reviewed literature evaluating the benefits of this therapy specifically for complex regional pain syndrome and showing superiority to standard of care. Thus, transcutaneous electrical modulation pain processing provided from 12/03/18 through 5/14/19 was not likely to have been more beneficial than any available standard therapy.
Appeal type: Experimental
Decision: Upheld

Summary Reviewer 3

A 57-year-old male requested authorization and coverage for implantation of device (the Coflex device) between the bones of the spine. The Health Insurer has denied this request indicating that the requested device is considered investigational for treatment of the enrollees chronic lower back pain. The physician reviewer found that the medical literature does not demonstrate the superior benefits of the requested device in this clinical setting. While there is some evidence to indicate that the Coflex interlaminar stabilization implant has been effective, the literature appears to support its use in patients with low grade spinal stenosis. In this patients case, his symptoms are more consistent with high grade or severe spinal stenosis. Further studies are needed in order to demonstrate the superior efficacy of the requested device for patients in this clinical setting. Accordingly, implantation of the Coflex device between the bones of the spine is not likely to be more beneficial than the standard available options for the treatment of this patient. Based upon the information set forth above, the requested device 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.